Provider Demographics
NPI:1992028708
Name:FAVELA DENTAL CORP.
Entity Type:Organization
Organization Name:FAVELA DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:VO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-499-1200
Mailing Address - Street 1:26895 ALISO CREEK RD STE B-712
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-5301
Mailing Address - Country:US
Mailing Address - Phone:949-499-1200
Mailing Address - Fax:949-499-2266
Practice Address - Street 1:26895 ALISO CREEK ROAD, SUITE B-712
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-5301
Practice Address - Country:US
Practice Address - Phone:949-499-1200
Practice Address - Fax:949-499-2266
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-08
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA423101223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty