| Dba Crenshaw Professional Dental Center | |
|
3015 Crenshaw Blvd Los Angeles CA 90016-4264 | |
| (323) 731-0801 | |
| (323) 731-1351 |
| Full Name | Dba Crenshaw Professional Dental Center |
|---|---|
| Speciality | Dentist |
| Location | 3015 Crenshaw Blvd, Los Angeles, California |
| Authorized Official Name and Position | Jeanine T Black (BUSINESS ADMINISTRATOR) |
| Authorized Official Contact | 3237310801 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Dba Crenshaw Professional Dental Center 3015 Crenshaw Blvd Los Angeles CA 90016-4264 Ph: (323) 731-0801 | Dba Crenshaw Professional Dental Center 3015 Crenshaw Blvd Los Angeles CA 90016-4264 Ph: (323) 731-0801 |
| NPI Number | 1871631622 |
|---|---|
| Provider Enumeration Date | 02/02/2007 |
| Last Update Date | 04/11/2017 |
| Medicare PECOS PAC ID | 9032495098 |
|---|---|
| Medicare Enrollment ID | O20170406000916 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1871631622 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223G0001X | Dentist - General Practice | 17880 (California) | Primary |
| Provider Name | James T Black |
|---|---|
| Provider Type | Practitioner - Oral Surgery |
| Provider Identifiers | NPI Number: 1801092648 PECOS PAC ID: 8820393515 Enrollment ID: I20170418001588 |
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