Provider Demographics
NPI:1760535322
Name:DR. PORFIRIO S. MARAVILLA JR. DMD INC
Entity Type:Organization
Organization Name:DR. PORFIRIO S. MARAVILLA JR. DMD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES.
Authorized Official - Prefix:DR
Authorized Official - First Name:PORFIRIO
Authorized Official - Middle Name:SANTOS
Authorized Official - Last Name:MARAVILLA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DMD
Authorized Official - Phone:213-388-2466
Mailing Address - Street 1:3540 WILSHIRE BLVD STE 208
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010-2346
Mailing Address - Country:US
Mailing Address - Phone:213-388-2466
Mailing Address - Fax:213-388-9775
Practice Address - Street 1:3540 WILSHIRE BLVD STE 208
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90010-2346
Practice Address - Country:US
Practice Address - Phone:213-388-2466
Practice Address - Fax:213-388-9775
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA323561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty