Provider Demographics
NPI:1639467061
Name:WESTERN DENTAL SERVICES, INC
Entity Type:Organization
Organization Name:WESTERN DENTAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PPO COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SILVIA
Authorized Official - Middle Name:S
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-480-3000
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4525
Mailing Address - Country:US
Mailing Address - Phone:714-480-3000
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:780 1ST ST
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-4972
Practice Address - Country:US
Practice Address - Phone:408-337-3620
Practice Address - Fax:408-337-3670
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-19
Last Update Date:2011-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90179-Medicaid