Provider Demographics
NPI:1023407947
Name:WEST VALLEY ENDODONTIC DENTAL GROUP
Entity type:Organization
Organization Name:WEST VALLEY ENDODONTIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:JOVICICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-986-6777
Mailing Address - Street 1:5363 BALBOA BLVD
Mailing Address - Street 2:SUITE 534
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2805
Mailing Address - Country:US
Mailing Address - Phone:818-986-6777
Mailing Address - Fax:818-986-6519
Practice Address - Street 1:5363 BALBOA BLVD
Practice Address - Street 2:SUITE 534
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2805
Practice Address - Country:US
Practice Address - Phone:818-986-6777
Practice Address - Fax:818-986-6519
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA368781223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty