Provider Demographics
NPI:1558588566
Name:DENTALVILLE
Entity Type:Organization
Organization Name:DENTALVILLE
Other - Org Name:LEONID GLOSMAN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGEMENT
Authorized Official - Prefix:
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:
Authorized Official - Last Name:PAROCUA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-559-1517
Mailing Address - Street 1:833 W. WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640
Mailing Address - Country:US
Mailing Address - Phone:323-266-1000
Mailing Address - Fax:323-890-2955
Practice Address - Street 1:833 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4735
Practice Address - Country:US
Practice Address - Phone:323-266-1000
Practice Address - Fax:323-890-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26405122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty