Provider Demographics
NPI:1609836469
Name:PROUTY, ERIC A (DMD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:A
Last Name:PROUTY
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 CUERVO DR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1742
Mailing Address - Country:US
Mailing Address - Phone:949-837-3593
Mailing Address - Fax:
Practice Address - Street 1:3151 AIRWAY AVE
Practice Address - Street 2:SUITE M2
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4607
Practice Address - Country:US
Practice Address - Phone:714-668-9811
Practice Address - Fax:714-668-9811
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-24
Last Update Date:2008-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA326511223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice