Provider Demographics
NPI:1548612856
Name:DR. DEZA'S DENTAL OFFICE INC.
Entity Type:Organization
Organization Name:DR. DEZA'S DENTAL OFFICE INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROCIO
Authorized Official - Middle Name:
Authorized Official - Last Name:DEZA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-697-0909
Mailing Address - Street 1:23080 ALESSANDRO BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92553-9674
Mailing Address - Country:US
Mailing Address - Phone:951-697-0909
Mailing Address - Fax:951-697-1116
Practice Address - Street 1:23080 ALESSANDRO BLVD STE 201
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9674
Practice Address - Country:US
Practice Address - Phone:951-697-0909
Practice Address - Fax:951-697-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2016-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43332261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1982707907Medicaid