Provider Demographics
NPI:1780748517
Name:NACILLA, RAMON ZABALA (DMD)
Entity type:Individual
Prefix:DR
First Name:RAMON
Middle Name:ZABALA
Last Name:NACILLA
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:DR
Other - First Name:RAMON
Other - Middle Name:ZABALA
Other - Last Name:NACILLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DMD
Mailing Address - Street 1:4985 EAGLE ROCK BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90041-1921
Mailing Address - Country:US
Mailing Address - Phone:323-254-1212
Mailing Address - Fax:323-254-1183
Practice Address - Street 1:4985 EAGLE ROCK BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90041-1921
Practice Address - Country:US
Practice Address - Phone:323-254-1212
Practice Address - Fax:323-254-1183
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA279071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA27907-01OtherDENTI-CAL