Provider Demographics
NPI:1871858688
Name:FAMILY DENTAL
Entity Type:Organization
Organization Name:FAMILY DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENR
Authorized Official - Prefix:
Authorized Official - First Name:LETICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMACHO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-972-2506
Mailing Address - Street 1:516 W 17TH ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-3677
Mailing Address - Country:US
Mailing Address - Phone:714-972-2606
Mailing Address - Fax:714-972-2607
Practice Address - Street 1:700 W 19TH ST
Practice Address - Street 2:SUITE C
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3517
Practice Address - Country:US
Practice Address - Phone:714-722-9027
Practice Address - Fax:714-722-9028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA557381223G0001X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No305R00000XManaged Care OrganizationsPreferred Provider OrganizationGroup - Single Specialty