Provider Demographics
NPI:1700025178
Name:CREATING SMILES DENTAL OFFICE
Entity Type:Organization
Organization Name:CREATING SMILES DENTAL OFFICE
Other - Org Name:ROBERT A. WITEK, DDS,INC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:A
Authorized Official - Last Name:WITEK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-302-9800
Mailing Address - Street 1:31940 TEMECULA PKWY STE C-2
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-9498
Mailing Address - Country:US
Mailing Address - Phone:951-302-9800
Mailing Address - Fax:951-302-6012
Practice Address - Street 1:31940 TEMECULA PKWY STE C-2
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92592-9498
Practice Address - Country:US
Practice Address - Phone:951-302-9800
Practice Address - Fax:951-302-6012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34443122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6248990001Medicare NSC