Provider Demographics
NPI:1497003685
Name:GLENDALE SURGICAL ASSOCIATES, LP
Entity Type:Organization
Organization Name:GLENDALE SURGICAL ASSOCIATES, LP
Other - Org Name:PACIFIC COAST OMS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DIANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LAFAURIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:818-241-4217
Mailing Address - Street 1:11550 INDIAN HILLS RD STE 270
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91345-1244
Mailing Address - Country:US
Mailing Address - Phone:818-365-5636
Mailing Address - Fax:818-365-5639
Practice Address - Street 1:11550 INDIAN HILLS RD STE 270
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1244
Practice Address - Country:US
Practice Address - Phone:818-365-5636
Practice Address - Fax:818-365-5639
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GLENDALE SURGICAL ASSOCIATES, LP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOMS941223S0112X
CA214131223S0112X
CAOMS711223S0112X
CA379451223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty