Provider Demographics
NPI:1770639437
Name:WESTERN DENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:WESTERN DENTAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PPOCOORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CINDY
Authorized Official - Middle Name:E
Authorized Official - Last Name:AVALOS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-480-3000
Mailing Address - Street 1:750 S INDIAN HILL BLVD STE F
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-5450
Mailing Address - Country:US
Mailing Address - Phone:909-625-7395
Mailing Address - Fax:909-625-7812
Practice Address - Street 1:750 S INDIAN HILL BLVD STE F
Practice Address - Street 2:
Practice Address - City:CLAREMONT
Practice Address - State:CA
Practice Address - Zip Code:91711-5450
Practice Address - Country:US
Practice Address - Phone:909-625-7395
Practice Address - Fax:909-625-7812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90179-58Medicaid