Provider Demographics
NPI:1659563120
Name:M.G. PROFESSIONAL DENTAL CORPORATION
Entity Type:Organization
Organization Name:M.G. PROFESSIONAL DENTAL CORPORATION
Other - Org Name:MGR DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAYRA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANCHEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-274-0732
Mailing Address - Street 1:525 S. AZUSA WAY
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744
Mailing Address - Country:US
Mailing Address - Phone:626-810-0045
Mailing Address - Fax:
Practice Address - Street 1:525 S. AZUSA WAY
Practice Address - Street 2:
Practice Address - City:LA PUENTE
Practice Address - State:CA
Practice Address - Zip Code:91744
Practice Address - Country:US
Practice Address - Phone:626-810-0045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2007-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA469451223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92678-01OtherDENTICAL PROVIDER