Provider Demographics
NPI:1497914154
Name:AMERICAN DENTAL GROUP
Entity Type:Organization
Organization Name:AMERICAN DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:PRESCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:626-337-7271
Mailing Address - Street 1:436 N SUNSET AVE
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91790-1652
Mailing Address - Country:US
Mailing Address - Phone:626-337-7271
Mailing Address - Fax:626-337-8125
Practice Address - Street 1:436 N SUNSET AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-1652
Practice Address - Country:US
Practice Address - Phone:626-337-7271
Practice Address - Fax:626-337-8125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA355371223G0001X
CA149151223S0112X
CA253061223X0400X
CARDH16115124Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
No124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty