Provider Demographics
NPI:1588901979
Name:I ZAK DDS PROF DENTAL CORP
Entity type:Organization
Organization Name:I ZAK DDS PROF DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:
Authorized Official - Last Name:ZAK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-706-5273
Mailing Address - Street 1:10501 LAKEWOOD BLVD
Mailing Address - Street 2:STE A & B
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-2709
Mailing Address - Country:US
Mailing Address - Phone:562-862-2341
Mailing Address - Fax:562-861-8350
Practice Address - Street 1:10501 LAKEWOOD BLVD
Practice Address - Street 2:STE A & B
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-2709
Practice Address - Country:US
Practice Address - Phone:562-862-2341
Practice Address - Fax:562-861-8350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-07
Last Update Date:2016-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26453122300000X
CA61574122300000X
CA46372122300000X
CA55241122300000X
CA48766122300000X
CA206731223E0200X
CA603151223P0221X
CA481981223S0112X
CA57513C1223X0400X
CA38238122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38238OtherDENTAL LICENCE NUMBER