Provider Demographics
NPI:1568645216
Name:MOUCHAMEL DENTAL CORPORATION
Entity Type:Organization
Organization Name:MOUCHAMEL DENTAL CORPORATION
Other - Org Name:ABC DENTAL GROUP
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAM
Authorized Official - Middle Name:
Authorized Official - Last Name:MOUCHAMEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-557-2299
Mailing Address - Street 1:1319 N SAN FERNANDO BLVD
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91504
Mailing Address - Country:US
Mailing Address - Phone:818-557-2299
Mailing Address - Fax:818-557-8749
Practice Address - Street 1:1319 N SAN FERNANDO BLVD
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91504
Practice Address - Country:US
Practice Address - Phone:818-557-2299
Practice Address - Fax:818-557-8749
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40861122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9109701OtherDENTICAL