Provider Demographics
NPI:1124185194
Name:LOMA LINDA UNIVERISTY
Entity Type:Organization
Organization Name:LOMA LINDA UNIVERISTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RODNEY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:NEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-558-4543
Mailing Address - Street 1:LOMA LINDA UNIVERSITY--SCHOOL OF DENTISTRY
Mailing Address - Street 2:11092 ANDERSON STREET
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354
Mailing Address - Country:US
Mailing Address - Phone:909-558-4613
Mailing Address - Fax:909-558-4192
Practice Address - Street 1:LOMA LINDA UNIVERSITY--SCHOOL OF DENTISTRY
Practice Address - Street 2:11092 ANDERSON STREET
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-4613
Practice Address - Fax:909-558-4192
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20431223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG02000-01Medicaid