Provider Demographics
NPI:1992315956
Name:TALLAS, KIMBERLY MARIE
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:MARIE
Last Name:TALLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13909 PINNEY ST
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-3624
Mailing Address - Country:US
Mailing Address - Phone:213-248-0532
Mailing Address - Fax:
Practice Address - Street 1:9745 LAUREL CANYON
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331
Practice Address - Country:US
Practice Address - Phone:213-248-0532
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
89660126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant