Provider Demographics
NPI:1700448362
Name:EIDELSTEIN, DYANA (DMD)
Entity Type:Individual
Prefix:DR
First Name:DYANA
Middle Name:
Last Name:EIDELSTEIN
Suffix:
Gender:F
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30702 HILLTOP WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-2046
Mailing Address - Country:US
Mailing Address - Phone:949-813-6296
Mailing Address - Fax:
Practice Address - Street 1:2825 SANTA MONICA BLVD STE 310
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2429
Practice Address - Country:US
Practice Address - Phone:310-828-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-03
Last Update Date:2019-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS103849122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist