Provider Demographics
NPI:1457521361
Name:JOSEPH CERAVOLO DDS INC
Entity Type:Organization
Organization Name:JOSEPH CERAVOLO DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:CERAVOLO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-990-1636
Mailing Address - Street 1:322 CULVER BLVD
Mailing Address - Street 2:STE #274
Mailing Address - City:PLAYA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90293-7704
Mailing Address - Country:US
Mailing Address - Phone:310-990-1636
Mailing Address - Fax:
Practice Address - Street 1:1304 15TH ST
Practice Address - Street 2:STE 314
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-1809
Practice Address - Country:US
Practice Address - Phone:310-394-5879
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-06
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA485131223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty