Provider Demographics
NPI:1467642280
Name:PUENTE HILLS DENTAL GROUP
Entity Type:Organization
Organization Name:PUENTE HILLS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:EVANGELOS
Authorized Official - Middle Name:
Authorized Official - Last Name:ROSSOPOULOS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-854-9530
Mailing Address - Street 1:1850 S AZUSA AVE STE 202
Mailing Address - Street 2:
Mailing Address - City:HACIENDA HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:91745-6853
Mailing Address - Country:US
Mailing Address - Phone:626-854-9530
Mailing Address - Fax:
Practice Address - Street 1:1850 S AZUSA AVE STE 202
Practice Address - Street 2:
Practice Address - City:HACIENDA HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:91745-6853
Practice Address - Country:US
Practice Address - Phone:626-854-9530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-27
Last Update Date:2007-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA310271223P0221X
CA366051223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty