Provider Demographics
NPI:1871181354
Name:SYLMAR FAMILY DENTAL PRACTICE CORP
Entity Type:Organization
Organization Name:SYLMAR FAMILY DENTAL PRACTICE CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:GUTIERREZ DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-384-4120
Mailing Address - Street 1:15283 AMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2155
Mailing Address - Country:US
Mailing Address - Phone:813-898-2523
Mailing Address - Fax:
Practice Address - Street 1:15283 AMBERLY DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33647-2155
Practice Address - Country:US
Practice Address - Phone:813-898-2523
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-01-09
Last Update Date:2021-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental