Provider Demographics
NPI: | 1619126174 |
---|---|
Name: | SAN FERNANDO DENTAL CARE |
Entity Type: | Organization |
Organization Name: | SAN FERNANDO DENTAL CARE |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | ADMINISTRATOR |
Authorized Official - Prefix: | MRS |
Authorized Official - First Name: | CATHERINE |
Authorized Official - Middle Name: | CARMMA |
Authorized Official - Last Name: | GEORGE |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 818-365-7107 |
Mailing Address - Street 1: | 1240 TRUMAN ST |
Mailing Address - Street 2: | STE 200 |
Mailing Address - City: | SAN FERNANDO |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 91340 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 818-365-7107 |
Mailing Address - Fax: | 818-365-0092 |
Practice Address - Street 1: | 1240 TRUMAN ST |
Practice Address - Street 2: | STE 200 |
Practice Address - City: | SAN FERNANDO |
Practice Address - State: | CA |
Practice Address - Zip Code: | 91340 |
Practice Address - Country: | US |
Practice Address - Phone: | 818-365-7107 |
Practice Address - Fax: | 818-365-0092 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2008-09-09 |
Last Update Date: | 2008-09-09 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 20609 | 122300000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 122300000X | Dental Providers | Dentist | Group - Single Specialty |