Provider Demographics
NPI:1780437996
Name:STAR TEK ADULT DENTAL GROUP
Entity type:Organization
Organization Name:STAR TEK ADULT DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:AMMONS
Authorized Official - Suffix:
Authorized Official - Credentials:HR
Authorized Official - Phone:661-312-1433
Mailing Address - Street 1:5449 HOLLYWOOD BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-3454
Mailing Address - Country:US
Mailing Address - Phone:323-203-2564
Mailing Address - Fax:
Practice Address - Street 1:815 CECIL AVE
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-1716
Practice Address - Country:US
Practice Address - Phone:323-203-2564
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JERRY L LANIER, DDS, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty