Provider Demographics
NPI:1689039570
Name:JUAN ANTONIO TREJO CANCHOLA DENTAL CORP
Entity Type:Organization
Organization Name:JUAN ANTONIO TREJO CANCHOLA DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:TREJO CANCHOLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-842-0803
Mailing Address - Street 1:9867 MAGNOLIA AVENUE
Mailing Address - Street 2:SUITE E
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503
Mailing Address - Country:US
Mailing Address - Phone:951-352-2112
Mailing Address - Fax:951-352-2088
Practice Address - Street 1:23030 LAKE FOREST DR
Practice Address - Street 2:SUITE 201
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1331
Practice Address - Country:US
Practice Address - Phone:949-305-8242
Practice Address - Fax:949-305-8238
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-21
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA610491223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty