Provider Demographics
NPI: | 1497248116 |
---|---|
Name: | RA AMADOR DENTAL GROUP DDS.INC. |
Entity Type: | Organization |
Organization Name: | RA AMADOR DENTAL GROUP DDS.INC. |
Other - Org Name: | AMADOR DENTAL CENTER |
Other - Org Type: | Doing Business As |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | DR |
Authorized Official - First Name: | ANN ROSELLE |
Authorized Official - Middle Name: | ALBANIA |
Authorized Official - Last Name: | AMADOR |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 626-512-5034 |
Mailing Address - Street 1: | 14302 TELEGRAPH RD |
Mailing Address - Street 2: | |
Mailing Address - City: | WHITTIER |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 90604-2905 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 626-512-5034 |
Mailing Address - Fax: | 562-351-1693 |
Practice Address - Street 1: | 14302 TELEGRAPH RD |
Practice Address - Street 2: | |
Practice Address - City: | WHITTIER |
Practice Address - State: | CA |
Practice Address - Zip Code: | 90604-2905 |
Practice Address - Country: | US |
Practice Address - Phone: | 562-351-1687 |
Practice Address - Fax: | 562-351-1725 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2018-06-07 |
Last Update Date: | 2019-01-31 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |