Provider Demographics
NPI:1992195119
Name:KOA AND VALLARTA DENTAL CORP
Entity Type:Organization
Organization Name:KOA AND VALLARTA DENTAL CORP
Other - Org Name:ALLIANCE DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:VALLARTA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:408-946-1397
Mailing Address - Street 1:1474 N MILPITAS BLVD
Mailing Address - Street 2:
Mailing Address - City:MILPITAS
Mailing Address - State:CA
Mailing Address - Zip Code:95035-3118
Mailing Address - Country:US
Mailing Address - Phone:408-946-1397
Mailing Address - Fax:408-262-1337
Practice Address - Street 1:1474 N MILPITAS BLVD
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-3118
Practice Address - Country:US
Practice Address - Phone:408-946-1397
Practice Address - Fax:408-262-1337
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2015-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA568381223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty