Provider Demographics
NPI:1285816793
Name:VAN ALLEN, MIRIAM VITA (DDS)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:VITA
Last Name:VAN ALLEN
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 DEL AMO BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90713-1949
Mailing Address - Country:US
Mailing Address - Phone:310-500-9782
Mailing Address - Fax:310-203-9915
Practice Address - Street 1:5920 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90713-1949
Practice Address - Country:US
Practice Address - Phone:562-496-2000
Practice Address - Fax:562-497-2064
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-27
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA539581223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics