Provider Demographics
NPI:1790866309
Name:MORENO DENTAL GROUP, PDC
Entity Type:Organization
Organization Name:MORENO DENTAL GROUP, PDC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, TREAS.
Authorized Official - Prefix:DR
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:GALE
Authorized Official - Last Name:MORENO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-478-3036
Mailing Address - Street 1:3427 DEER PARK DR
Mailing Address - Street 2:SUITE #C
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2355
Mailing Address - Country:US
Mailing Address - Phone:209-478-3036
Mailing Address - Fax:209-478-0258
Practice Address - Street 1:3427 DEER PARK DR
Practice Address - Street 2:SUITE #C
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2355
Practice Address - Country:US
Practice Address - Phone:209-478-3036
Practice Address - Fax:209-478-0258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34387122300000X
CA54645122300000X
CA324911223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered122300000XDental ProvidersDentistGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1860612OtherSTATE CORPORATION NUMBER
CA33195579OtherSTATE OF CAL. EDD NUMBER