Provider Demographics
NPI:1619187747
Name:UNITED DENTAL
Entity Type:Organization
Organization Name:UNITED DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:C
Authorized Official - Last Name:GONZALEZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-444-5500
Mailing Address - Street 1:11912 VALLEY BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91732-3153
Mailing Address - Country:US
Mailing Address - Phone:626-444-5500
Mailing Address - Fax:626-444-4041
Practice Address - Street 1:11912 VALLEY BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-3153
Practice Address - Country:US
Practice Address - Phone:626-444-5500
Practice Address - Fax:626-444-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA470811223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92063-01OtherDENTI-CAL