Provider Demographics
NPI:1205021664
Name:CHILDRENS DENTAL CARE CENTER
Entity Type:Organization
Organization Name:CHILDRENS DENTAL CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE OWNER PEDIATRIC DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHEN DER
Authorized Official - Middle Name:J
Authorized Official - Last Name:CHIANG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-369-1177
Mailing Address - Street 1:2219 S HACIENDA BLVD
Mailing Address - Street 2:100
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745
Mailing Address - Country:US
Mailing Address - Phone:626-369-1177
Mailing Address - Fax:626-369-1186
Practice Address - Street 1:2219 S HACIENDA BLVD
Practice Address - Street 2:100
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745
Practice Address - Country:US
Practice Address - Phone:626-369-1177
Practice Address - Fax:626-369-1186
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB386601223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB3866001Medicaid