Provider Demographics
NPI:1427201151
Name:PHILLIPS RANCH DENTAL GROUP
Entity Type:Organization
Organization Name:PHILLIPS RANCH DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JODIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:RAMIREZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-620-0321
Mailing Address - Street 1:4 VILLAGE LOOP RD
Mailing Address - Street 2:B2
Mailing Address - City:PHILLIPS RANCH
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4891
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4 VILLAGE LOOP RD
Practice Address - Street 2:B2
Practice Address - City:PHILLIPS RANCH
Practice Address - State:CA
Practice Address - Zip Code:91766-4891
Practice Address - Country:US
Practice Address - Phone:909-620-0321
Practice Address - Fax:909-620-0324
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2008-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24452122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty