Provider Demographics
NPI:1740569631
Name:ALLEGIANCE DENTAL INC
Entity Type:Organization
Organization Name:ALLEGIANCE DENTAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:T
Authorized Official - Last Name:TANI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:858-279-6100
Mailing Address - Street 1:4690 GENESEE AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-3000
Mailing Address - Country:US
Mailing Address - Phone:858-279-6100
Mailing Address - Fax:858-279-6112
Practice Address - Street 1:4690 GENESEE AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-3000
Practice Address - Country:US
Practice Address - Phone:858-279-6100
Practice Address - Fax:858-279-6112
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-09
Last Update Date:2012-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32622122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty