Provider Demographics
NPI:1275772634
Name:HACIENDA DENTAL
Entity Type:Organization
Organization Name:HACIENDA DENTAL
Other - Org Name:EDWARD H GRUBER DDS
Other - Org Type:Other Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:VELASQUEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-871-3736
Mailing Address - Street 1:4022 NILES ST
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93306-4630
Mailing Address - Country:US
Mailing Address - Phone:661-871-3736
Mailing Address - Fax:661-871-7417
Practice Address - Street 1:1507 PANAMA LANE
Practice Address - Street 2:102
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307
Practice Address - Country:US
Practice Address - Phone:661-398-5555
Practice Address - Fax:661-398-5510
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDWARD H. GRUBER DDS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-02-09
Last Update Date:2009-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33020261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental