Provider Demographics
NPI:1093145237
Name:DENTAL CENTER OF SAN MIGUEL
Entity Type:Organization
Organization Name:DENTAL CENTER OF SAN MIGUEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERICK
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:STUART
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-892-2649
Mailing Address - Street 1:8781 VAN NUYS BLVD
Mailing Address - Street 2:2ND FLR.
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-2401
Mailing Address - Country:US
Mailing Address - Phone:818-892-2649
Mailing Address - Fax:
Practice Address - Street 1:8781 VAN NUYS BLVD
Practice Address - Street 2:2ND FLR.
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-2401
Practice Address - Country:US
Practice Address - Phone:818-892-2649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREDERICK EDWIN STUART
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA248751223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty