Provider Demographics
NPI:1790939262
Name:PROCARE DENTAL - VICTORVILLE
Entity Type:Organization
Organization Name:PROCARE DENTAL - VICTORVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEY
Authorized Official - Middle Name:SORIANO
Authorized Official - Last Name:TIRADOR
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-951-9997
Mailing Address - Street 1:12602 AMARGOSA RD
Mailing Address - Street 2:SUITE D
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-7640
Mailing Address - Country:US
Mailing Address - Phone:760-951-9997
Mailing Address - Fax:760-962-9424
Practice Address - Street 1:12602 AMARGOSA RD
Practice Address - Street 2:SUITE D
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-7640
Practice Address - Country:US
Practice Address - Phone:760-951-9997
Practice Address - Fax:760-962-9424
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PROCARE DENTAL - BARSTOW
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-11-11
Last Update Date:2008-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50993122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty