Provider Demographics
NPI:1528220977
Name:PACIFIC SMILE DENTAL CLINIC
Entity Type:Organization
Organization Name:PACIFIC SMILE DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:ALANIZ
Authorized Official - Suffix:II
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-905-2552
Mailing Address - Street 1:545 W LA HABRA BLVD
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-5307
Mailing Address - Country:US
Mailing Address - Phone:562-905-2552
Mailing Address - Fax:562-905-2772
Practice Address - Street 1:545 W LA HABRA BLVD
Practice Address - Street 2:
Practice Address - City:LA HABRA
Practice Address - State:CA
Practice Address - Zip Code:90631-5307
Practice Address - Country:US
Practice Address - Phone:562-905-2552
Practice Address - Fax:562-905-2772
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD47031122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG89574-01Medicaid