Provider Demographics
NPI:1700367596
Name:VADIM KONVISER DDS A PROFESSIONAL CORP
Entity Type:Organization
Organization Name:VADIM KONVISER DDS A PROFESSIONAL CORP
Other - Org Name:OCEANBREEZE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:VADIM
Authorized Official - Middle Name:
Authorized Official - Last Name:KONVISER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-578-2500
Mailing Address - Street 1:4644 LINCOLN BLVD STE 404
Mailing Address - Street 2:
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6380
Mailing Address - Country:US
Mailing Address - Phone:310-578-2500
Mailing Address - Fax:
Practice Address - Street 1:4644 LINCOLN BLVD STE 404
Practice Address - Street 2:
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-6380
Practice Address - Country:US
Practice Address - Phone:310-578-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-08-28
Last Update Date:2018-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA510951223G0001X
510951223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty