Provider Demographics
NPI:1447469465
Name:SEVILLE DENTAL CENTER
Entity type:Organization
Organization Name:SEVILLE DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:323-582-6938
Mailing Address - Street 1:7705 SEVILLE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-6315
Mailing Address - Country:US
Mailing Address - Phone:323-582-6938
Mailing Address - Fax:
Practice Address - Street 1:7705 SEVILLE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-6315
Practice Address - Country:US
Practice Address - Phone:323-582-6938
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA263421223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9021602OtherDENTICAL NUMBER