Provider Demographics
NPI:1386727667
Name:KLEINMAN & WALLACE PROFESSIONAL DENTAL CORP
Entity type:Organization
Organization Name:KLEINMAN & WALLACE PROFESSIONAL DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:NATHAN
Authorized Official - Last Name:KLEINMAN
Authorized Official - Suffix:
Authorized Official - Credentials:GENERAL DENTIST
Authorized Official - Phone:323-752-3116
Mailing Address - Street 1:8615 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003
Mailing Address - Country:US
Mailing Address - Phone:323-752-3116
Mailing Address - Fax:323-752-4104
Practice Address - Street 1:8615 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003
Practice Address - Country:US
Practice Address - Phone:323-752-3116
Practice Address - Fax:323-752-4104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty