Provider Demographics
NPI:1205978566
Name:PEREZ FABIAN, ROSA DALIA (DDS)
Entity type:Individual
Prefix:
First Name:ROSA
Middle Name:DALIA
Last Name:PEREZ FABIAN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 S CARMONA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019
Mailing Address - Country:US
Mailing Address - Phone:323-934-1503
Mailing Address - Fax:323-934-1503
Practice Address - Street 1:2021 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 310E
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404
Practice Address - Country:US
Practice Address - Phone:310-315-9690
Practice Address - Fax:310-828-6181
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA359671223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADK035967OtherCA STATE BOARD