Provider Demographics
NPI:1053895565
Name:LILI MIRTORABI D.D.S A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:LILI MIRTORABI D.D.S A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GABRIELA
Authorized Official - Middle Name:
Authorized Official - Last Name:VALDOVINOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:323-228-9282
Mailing Address - Street 1:7722 SEVILLE AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-6316
Mailing Address - Country:US
Mailing Address - Phone:844-347-5794
Mailing Address - Fax:
Practice Address - Street 1:2368 PICO BOULEVARD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006
Practice Address - Country:US
Practice Address - Phone:844-347-5794
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LILI MIRTORABI, D.D.S., M.S., A PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-09-20
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020669521OtherORTHODONTIST