Provider Demographics
NPI:1871772368
Name:DENTALVILLE
Entity type:Organization
Organization Name:DENTALVILLE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGIONAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KOZYR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-804-1972
Mailing Address - Street 1:945 S RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89145-6230
Mailing Address - Country:US
Mailing Address - Phone:702-258-8216
Mailing Address - Fax:702-870-0974
Practice Address - Street 1:1180 S BEVERLY DR STE 401
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-1156
Practice Address - Country:US
Practice Address - Phone:310-804-1972
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-31
Last Update Date:2007-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3580122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty