Provider Demographics
NPI:1881711281
Name:UNTALAN DENTAL CORPORATION
Entity type:Organization
Organization Name:UNTALAN DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARISE
Authorized Official - Middle Name:R
Authorized Official - Last Name:UNTALAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:213-385-3828
Mailing Address - Street 1:730 S WESTERN AVE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90005-3193
Mailing Address - Country:US
Mailing Address - Phone:213-385-3828
Mailing Address - Fax:213-385-2144
Practice Address - Street 1:730 S WESTERN AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90005-3193
Practice Address - Country:US
Practice Address - Phone:213-385-3828
Practice Address - Fax:213-385-2144
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA499841223G0001X
CA496931223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB49693-01OtherDELTA DENTAL HEALTHY FAMI
CAG9241201OtherDENTICAL PROV NUM