Provider Demographics
NPI:1104234665
Name:SYLMAR DENTAL CORP.
Entity type:Organization
Organization Name:SYLMAR DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VYNIAMIN
Authorized Official - Middle Name:G
Authorized Official - Last Name:GURALNIK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-365-9177
Mailing Address - Street 1:12610 GLENOAKS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:SYLMAR
Mailing Address - State:CA
Mailing Address - Zip Code:91342-4785
Mailing Address - Country:US
Mailing Address - Phone:818-365-9177
Mailing Address - Fax:818-361-6697
Practice Address - Street 1:12610 GLENOAKS BLVD FL 2
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-4785
Practice Address - Country:US
Practice Address - Phone:818-365-9177
Practice Address - Fax:818-361-6697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA302181223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA30218Medicaid