Provider Demographics
NPI:1023370426
Name:M ROBERTA DORNAN DDS INC
Entity Type:Organization
Organization Name:M ROBERTA DORNAN DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MAUREEN
Authorized Official - Middle Name:ROBERTA
Authorized Official - Last Name:DORNAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-544-2020
Mailing Address - Street 1:13422 NEWPORT AVE STE B
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3746
Mailing Address - Country:US
Mailing Address - Phone:714-544-2020
Mailing Address - Fax:714-544-7620
Practice Address - Street 1:13422 NEWPORT AVE STE B
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3746
Practice Address - Country:US
Practice Address - Phone:714-544-2020
Practice Address - Fax:714-544-7620
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-12
Last Update Date:2018-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA301071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty