Provider Demographics
NPI:1588800510
Name:COURTNEY RAY MITTELMARK, D.M.D., M.S.D., A PROFESSIONAL CORP.
Entity Type:Organization
Organization Name:COURTNEY RAY MITTELMARK, D.M.D., M.S.D., A PROFESSIONAL CORP.
Other - Org Name:PLAYA VISTA ORTHODONTICS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:FABIOLA
Authorized Official - Middle Name:
Authorized Official - Last Name:ORTEGA-FRASCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-216-0101
Mailing Address - Street 1:8540 S SEPULVEDA BLVD
Mailing Address - Street 2:#700
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3807
Mailing Address - Country:US
Mailing Address - Phone:310-216-0101
Mailing Address - Fax:310-216-1279
Practice Address - Street 1:8540 S SEPULVEDA BLVD
Practice Address - Street 2:#700
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3807
Practice Address - Country:US
Practice Address - Phone:310-216-0101
Practice Address - Fax:310-216-1279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-22
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA61908261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Single Specialty