Provider Demographics
NPI:1326612607
Name:ELGENDI DENTAL CORPORATION
Entity Type:Organization
Organization Name:ELGENDI DENTAL CORPORATION
Other - Org Name:HACIENDA FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUPE
Authorized Official - Middle Name:
Authorized Official - Last Name:GOMEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-336-2878
Mailing Address - Street 1:818 N HACIENDA BLVD STE J
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-2806
Mailing Address - Country:US
Mailing Address - Phone:626-336-2878
Mailing Address - Fax:626-336-2879
Practice Address - Street 1:818 N HACIENDA BLVD STE J
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744-2806
Practice Address - Country:US
Practice Address - Phone:626-336-2878
Practice Address - Fax:626-336-2879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-19
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental