Provider Demographics
NPI:1891984928
Name:IDA GANAPOLSKY, D.D.S. A PROFESSIONAL DENTAL CORP.
Entity Type:Organization
Organization Name:IDA GANAPOLSKY, D.D.S. A PROFESSIONAL DENTAL CORP.
Other - Org Name:SMILES DENTAL PRACTICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-269-5221
Mailing Address - Street 1:3356 E OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90023-3724
Mailing Address - Country:US
Mailing Address - Phone:323-269-5221
Mailing Address - Fax:323-269-5730
Practice Address - Street 1:3356 E OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90023-3724
Practice Address - Country:US
Practice Address - Phone:323-269-5221
Practice Address - Fax:323-269-5730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA341031223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty