Provider Demographics
NPI:1013212919
Name:HERSEL, EVLYNE
Entity Type:Individual
Prefix:DR
First Name:EVLYNE
Middle Name:
Last Name:HERSEL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1627 CAMDEN AVE
Mailing Address - Street 2:APT #305
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-3547
Mailing Address - Country:US
Mailing Address - Phone:310-429-8043
Mailing Address - Fax:310-444-7119
Practice Address - Street 1:1627 CAMDEN AVE
Practice Address - Street 2:APT #305
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-3547
Practice Address - Country:US
Practice Address - Phone:310-429-8043
Practice Address - Fax:310-444-7119
Is Sole Proprietor?:No
Enumeration Date:2011-01-24
Last Update Date:2011-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59814122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist