Provider Demographics
NPI:1124224985
Name:MARY ANN CORPUS PROFESSIONAL DENTAL CORPORATION
Entity type:Organization
Organization Name:MARY ANN CORPUS PROFESSIONAL DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:AREVALO
Authorized Official - Last Name:CORPUS
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-788-7181
Mailing Address - Street 1:15720 VENTURA BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-2983
Mailing Address - Country:US
Mailing Address - Phone:818-788-7181
Mailing Address - Fax:818-907-1891
Practice Address - Street 1:15720 VENTURA BLVD
Practice Address - Street 2:SUITE 301
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2914
Practice Address - Country:US
Practice Address - Phone:818-788-7181
Practice Address - Fax:818-907-1891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD41381122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty