Provider Demographics
NPI:1639375488
Name:DENTALVILLE
Entity Type:Organization
Organization Name:DENTALVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONID
Authorized Official - Middle Name:
Authorized Official - Last Name:GLOSMAN
Authorized Official - Suffix:SR
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-266-1000
Mailing Address - Street 1:7864 VAN NUYS BLVD
Mailing Address - Street 2:
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-6069
Mailing Address - Country:US
Mailing Address - Phone:818-989-2400
Mailing Address - Fax:818-989-2457
Practice Address - Street 1:7864 VAN NUYS BLVD
Practice Address - Street 2:
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-6069
Practice Address - Country:US
Practice Address - Phone:818-989-2400
Practice Address - Fax:818-989-2457
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB26405-03122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty