Provider Demographics
NPI:1316141732
Name:MOUTON, MARSHA E (DDS)
Entity type:Individual
Prefix:DR
First Name:MARSHA
Middle Name:E
Last Name:MOUTON
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 1:112 S MARKET ST STE 404
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1712
Mailing Address - Country:US
Mailing Address - Phone:310-890-3100
Mailing Address - Fax:
Practice Address - Street 1:6820 LA TIJERA BLVD
Practice Address - Street 2:STE 205
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-1908
Practice Address - Country:US
Practice Address - Phone:310-256-4326
Practice Address - Fax:310-835-0088
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40688122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No122300000XDental ProvidersDentist