Provider Demographics
NPI:1033847520
Name:VON WESTERNHAGEN DENTAL CORPORATION
Entity Type:Organization
Organization Name:VON WESTERNHAGEN DENTAL CORPORATION
Other - Org Name:CANAM DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STAFF
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:STATHAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-274-4546
Mailing Address - Street 1:9610 SIERRA AVE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9610 SIERRA AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335
Practice Address - Country:US
Practice Address - Phone:909-219-8700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-11
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty