Provider Demographics
NPI:1245386234
Name:WESTERN DENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:WESTERN DENTAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PREET
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-571-3372
Mailing Address - Street 1:14244 HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-7008
Mailing Address - Country:US
Mailing Address - Phone:310-219-1234
Mailing Address - Fax:310-978-0380
Practice Address - Street 1:14244 HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-7008
Practice Address - Country:US
Practice Address - Phone:310-219-1234
Practice Address - Fax:310-978-0380
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90179-43Medicaid