Provider Demographics
NPI:1265853881
Name:ROBERT T CADALSO JR PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:ROBERT T CADALSO JR PROFESSIONAL DENTAL CORPORATION
Other - Org Name:GENESIS DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:TOMAS
Authorized Official - Last Name:CADALSO
Authorized Official - Suffix:JR
Authorized Official - Credentials:D DS
Authorized Official - Phone:949-770-5266
Mailing Address - Street 1:24896 CHRISANTA DR
Mailing Address - Street 2:SUITE 110
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-4800
Mailing Address - Country:US
Mailing Address - Phone:949-770-5266
Mailing Address - Fax:949-770-7534
Practice Address - Street 1:24896 CHRISANTA DR
Practice Address - Street 2:STE 110
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-4800
Practice Address - Country:US
Practice Address - Phone:949-770-5266
Practice Address - Fax:949-770-7534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-27
Last Update Date:2014-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30639261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7008550001Medicare NSC