Provider Demographics
NPI:1588850622
Name:DR. CARMELITA SY-PRUDENCIO PROFESSIONAL DENTAL CORP.
Entity Type:Organization
Organization Name:DR. CARMELITA SY-PRUDENCIO PROFESSIONAL DENTAL CORP.
Other - Org Name:FAMILY DENTISTRY OF TEMECULA VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:CARMELITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SY-PRUDENCIO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:951-693-5220
Mailing Address - Street 1:29760 RANCHO CALIFORNIA RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-5288
Mailing Address - Country:US
Mailing Address - Phone:951-693-5220
Mailing Address - Fax:951-693-5222
Practice Address - Street 1:29760 RANCHO CALIFORNIA RD
Practice Address - Street 2:SUITE 108
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-5288
Practice Address - Country:US
Practice Address - Phone:951-693-5220
Practice Address - Fax:951-693-5222
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-22
Last Update Date:2007-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA411311223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty