Provider Demographics
NPI:1811920705
Name:MAZZELLA, PETER
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:
Last Name:MAZZELLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25550 HAWTHORNE BLVD
Mailing Address - Street 2:STE 305
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6831
Mailing Address - Country:US
Mailing Address - Phone:310-375-1000
Mailing Address - Fax:310-375-1066
Practice Address - Street 1:2945 ROLLING HILLS RD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-7146
Practice Address - Country:US
Practice Address - Phone:310-530-8602
Practice Address - Fax:310-530-5190
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA340271223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954662416OtherTIN