Provider Demographics
NPI:1588209712
Name:RENATA CARVALHO DA FONSECA DDS., A DENTAL CORPORATION
Entity Type:Organization
Organization Name:RENATA CARVALHO DA FONSECA DDS., A DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RENATA
Authorized Official - Middle Name:CARVALHO
Authorized Official - Last Name:DA FONSECA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-463-3294
Mailing Address - Street 1:578 WASHINGTON BLVD UNIT 523
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-5421
Mailing Address - Country:US
Mailing Address - Phone:310-463-3294
Mailing Address - Fax:
Practice Address - Street 1:23101 SHERMAN PL STE 201
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-2019
Practice Address - Country:US
Practice Address - Phone:818-716-8424
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-12
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223D0004XDental ProvidersDentistDentist AnesthesiologistGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty