1477106557 NPI number — DR. BRAN'D HUTALLA ESTELLA DMD

Table of content: DR. BRAN'D HUTALLA ESTELLA DMD (NPI 1477106557)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477106557 NPI number — DR. BRAN'D HUTALLA ESTELLA DMD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ESTELLA
Provider First Name:
BRAN'D
Provider Middle Name:
HUTALLA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DMD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477106557
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16733 LA VEDA AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANYON COUNTRY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91387-1723
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
323-369-8228
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 W RANCHO VISTA BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PALMDALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93551-3010
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-402-0029
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  104009 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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