Provider Demographics
NPI:1609385020
Name:WILLOW GLEN DENTAL SPECIALISTS
Entity Type:Organization
Organization Name:WILLOW GLEN DENTAL SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ROSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ADAME
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-266-6144
Mailing Address - Street 1:1706 WILLOW ST STE A
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-5216
Mailing Address - Country:US
Mailing Address - Phone:408-478-9081
Mailing Address - Fax:408-904-7201
Practice Address - Street 1:1706 WILLOW ST STE A
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95125-5216
Practice Address - Country:US
Practice Address - Phone:408-504-4935
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-28
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DDS54347122300000X
1223E0200X, 1223P0300X, 1223S0112X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
No122300000XDental ProvidersDentistGroup - Single Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty