Provider Demographics
NPI:1386920874
Name:MIKE IMBERMAN D M D INC A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:MIKE IMBERMAN D M D INC A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DMD, PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:IMBERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:818-345-5300
Mailing Address - Street 1:18425 BURBANK BLVD
Mailing Address - Street 2:STE 709
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-2806
Mailing Address - Country:US
Mailing Address - Phone:818-345-5300
Mailing Address - Fax:818-345-3863
Practice Address - Street 1:18425 BURBANK BLVD
Practice Address - Street 2:STE 709
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-2806
Practice Address - Country:US
Practice Address - Phone:818-345-5300
Practice Address - Fax:818-345-3863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-27
Last Update Date:2012-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA323241223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty