Provider Demographics
NPI:1376906974
Name:VILLAGRAN, WILLY
Entity Type:Individual
Prefix:
First Name:WILLY
Middle Name:
Last Name:VILLAGRAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S BUSH ST
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-4129
Mailing Address - Country:US
Mailing Address - Phone:714-232-6769
Mailing Address - Fax:
Practice Address - Street 1:21229 HAWTHORNE BLVD STE A
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5501
Practice Address - Country:US
Practice Address - Phone:310-409-4265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-31
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA72577126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA72577Medicaid