Provider Demographics
NPI:1144384645
Name:WESTERN DENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:WESTERN DENTAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PPO COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARINA
Authorized Official - Middle Name:
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-480-3000
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4525
Mailing Address - Country:US
Mailing Address - Phone:714-480-3000
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:1282 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94102-4801
Practice Address - Country:US
Practice Address - Phone:415-552-1200
Practice Address - Fax:415-552-1296
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90179-40Medicaid