Provider Demographics
NPI:1396822029
Name:RACHO NIGUEL DENTAL GROUP
Entity Type:Organization
Organization Name:RACHO NIGUEL DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:RENE
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-249-4180
Mailing Address - Street 1:828 EMERALD BAY
Mailing Address - Street 2:
Mailing Address - City:LAGUNA BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92651
Mailing Address - Country:US
Mailing Address - Phone:949-249-4180
Mailing Address - Fax:
Practice Address - Street 1:30140 TOWN CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677
Practice Address - Country:US
Practice Address - Phone:949-249-4180
Practice Address - Fax:949-249-4185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37868122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty