Provider Demographics
NPI:1942442777
Name:SOUTHWEST DENTAL CENTER INC.
Entity Type:Organization
Organization Name:SOUTHWEST DENTAL CENTER INC.
Other - Org Name:HI DESERT DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LEONEED
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-723-5400
Mailing Address - Street 1:1745 W AVENUE K
Mailing Address - Street 2:SUITE C
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-6501
Mailing Address - Country:US
Mailing Address - Phone:661-723-5400
Mailing Address - Fax:661-723-3944
Practice Address - Street 1:1745 W AVENUE K
Practice Address - Street 2:SUITE C
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-6501
Practice Address - Country:US
Practice Address - Phone:661-723-5400
Practice Address - Fax:661-723-3944
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOUTHWEST DENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-25
Last Update Date:2016-07-27
Deactivation Date:2009-07-10
Deactivation Code:
Reactivation Date:2016-07-27
Provider Licenses
StateLicense IDTaxonomies
CA329361223G0001X
CA432661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA32936OtherLICENSE
CA43622OtherLICENSE
CA571310977OtherGORDON
CA571310977OtherGORDON