Provider Demographics
NPI:1972679124
Name:MARK TREYSTMAN DDS INC
Entity Type:Organization
Organization Name:MARK TREYSTMAN DDS INC
Other - Org Name:NEW CENTURY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:TREYSTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-653-5484
Mailing Address - Street 1:6333 WILSHIRE BLVD
Mailing Address - Street 2:207
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-5702
Mailing Address - Country:US
Mailing Address - Phone:323-653-5484
Mailing Address - Fax:323-653-5485
Practice Address - Street 1:6333 WILSHIRE BLVD
Practice Address - Street 2:207
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-5702
Practice Address - Country:US
Practice Address - Phone:323-653-5484
Practice Address - Fax:323-653-5485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2013-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45416122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD45416Medicaid
DW45416AMedicare ID - Type Unspecified
CAD45416Medicaid