Provider Demographics
NPI:1447670617
Name:REYNALDO D ECLAVEA, DMD, INC
Entity type:Organization
Organization Name:REYNALDO D ECLAVEA, DMD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REYNALDO
Authorized Official - Middle Name:DIMASIN
Authorized Official - Last Name:ECLAVEA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:323-660-3876
Mailing Address - Street 1:3508 W SUNSET BLVD # B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-2106
Mailing Address - Country:US
Mailing Address - Phone:323-660-3876
Mailing Address - Fax:323-660-0476
Practice Address - Street 1:3508 W SUNSET BLVD # B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-2106
Practice Address - Country:US
Practice Address - Phone:323-660-3876
Practice Address - Fax:323-660-0476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-25
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34952122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB34952-01OtherMEDICAL