Provider Demographics
NPI:1811186463
Name:WESTERN DENTAL SERVICES, INC
Entity Type:Organization
Organization Name:WESTERN DENTAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PREET
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-571-3372
Mailing Address - Street 1:530 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4525
Mailing Address - Country:US
Mailing Address - Phone:714-480-3000
Mailing Address - Fax:714-571-3560
Practice Address - Street 1:1560 W LACEY BLVD STE 107
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-3587
Practice Address - Country:US
Practice Address - Phone:559-589-6301
Practice Address - Fax:559-589-6312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2019-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92150Medicaid