Provider Demographics
NPI:1790349751
Name:VON WESTERNHAGEN DENTAL CORPORATION
Entity Type:Organization
Organization Name:VON WESTERNHAGEN DENTAL CORPORATION
Other - Org Name:CANAM DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:LEAD PROVIDER RELATIONS SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:ERICKA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOTO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:312-274-4581
Mailing Address - Street 1:350 N CLARK ST STE 600
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60654-4782
Mailing Address - Country:US
Mailing Address - Phone:312-274-4526
Mailing Address - Fax:
Practice Address - Street 1:520 E MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90003-3525
Practice Address - Country:US
Practice Address - Phone:323-521-5444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-25
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty