Provider Demographics
NPI: | 1790999506 |
---|---|
Name: | MISSION DENTAL CENTER |
Entity Type: | Organization |
Organization Name: | MISSION DENTAL CENTER |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | OPHELIA |
Authorized Official - Middle Name: | GARCIA- |
Authorized Official - Last Name: | ADEMCZUK |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 951-681-6611 |
Mailing Address - Street 1: | 8992 MISSION BLVD |
Mailing Address - Street 2: | SUITE A |
Mailing Address - City: | RIVERSIDE |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 92509-2874 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 951-681-6611 |
Mailing Address - Fax: | 951-681-6611 |
Practice Address - Street 1: | 8992 MISSION BLVD |
Practice Address - Street 2: | SUITE A |
Practice Address - City: | RIVERSIDE |
Practice Address - State: | CA |
Practice Address - Zip Code: | 92509-2874 |
Practice Address - Country: | US |
Practice Address - Phone: | 951-681-6611 |
Practice Address - Fax: | 951-681-6611 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-05-10 |
Last Update Date: | 2007-08-15 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 36540 | 302R00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 302R00000X | Managed Care Organizations | Health Maintenance Organization |