Provider Demographics
NPI:1346061793
Name:FERNANDES ORTHODONTICS
Entity type:Organization
Organization Name:FERNANDES ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:AVID
Authorized Official - Middle Name:
Authorized Official - Last Name:SEGURA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-670-1411
Mailing Address - Street 1:8540 S SEPULVEDA BLVD STE 1012
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-3819
Mailing Address - Country:US
Mailing Address - Phone:310-670-1411
Mailing Address - Fax:310-670-1968
Practice Address - Street 1:8540 S SEPULVEDA BLVD STE 1012
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90045-3819
Practice Address - Country:US
Practice Address - Phone:310-670-1411
Practice Address - Fax:310-670-1968
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FERNANDES ORTHODONTICS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-10-18
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty