Provider Demographics
NPI:1619721297
Name:EDWARD J FORMICA D.D.S., INC.
Entity Type:Organization
Organization Name:EDWARD J FORMICA D.D.S., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORMICA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-925-6444
Mailing Address - Street 1:26580 RIO VISTA DR
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544-6772
Mailing Address - Country:US
Mailing Address - Phone:951-235-1438
Mailing Address - Fax:951-848-9443
Practice Address - Street 1:1800 E FLORIDA AVE STE 340
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92544-4776
Practice Address - Country:US
Practice Address - Phone:951-925-6444
Practice Address - Fax:951-848-9443
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-11
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty