Provider Demographics
NPI:1689030462
Name:AMERIDENT HEALTH PRO, INC.
Entity Type:Organization
Organization Name:AMERIDENT HEALTH PRO, INC.
Other - Org Name:MARINA FAMILY DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:GINZBURG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-268-0646
Mailing Address - Street 1:13155 MINDANAO WAY
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6307
Mailing Address - Country:US
Mailing Address - Phone:310-268-0646
Mailing Address - Fax:310-268-0536
Practice Address - Street 1:13155 MINDANAO WAY
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6307
Practice Address - Country:US
Practice Address - Phone:310-268-0646
Practice Address - Fax:310-268-0536
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERIDENT HEALTH PRO, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-01-08
Last Update Date:2016-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40241122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty