Provider Demographics
NPI:1992028575
Name:MANDALAY CREST MANAGEMENT GROUP INC
Entity Type:Organization
Organization Name:MANDALAY CREST MANAGEMENT GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FLOYD
Authorized Official - Middle Name:JESSE
Authorized Official - Last Name:CAWTHON
Authorized Official - Suffix:III
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-479-8706
Mailing Address - Street 1:4924 BALBOA BLVD
Mailing Address - Street 2:#223
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-3402
Mailing Address - Country:US
Mailing Address - Phone:805-479-8706
Mailing Address - Fax:
Practice Address - Street 1:18663 VENTURA BLVD
Practice Address - Street 2:#200
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4197
Practice Address - Country:US
Practice Address - Phone:805-479-8706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6387580001Medicare NSC