Provider Demographics
NPI:1003109612
Name:CHATSWORTH FAMILY DENTAL GROUP
Entity type:Organization
Organization Name:CHATSWORTH FAMILY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:WOLFSON
Authorized Official - Suffix:
Authorized Official - Credentials:D,DS
Authorized Official - Phone:818-998-6446
Mailing Address - Street 1:21029 DEVONSHIRE ST
Mailing Address - Street 2:
Mailing Address - City:CHATSWORTH
Mailing Address - State:CA
Mailing Address - Zip Code:91311-2315
Mailing Address - Country:US
Mailing Address - Phone:818-998-6446
Mailing Address - Fax:
Practice Address - Street 1:21029 DEVONSHIRE ST
Practice Address - Street 2:
Practice Address - City:CHATSWORTH
Practice Address - State:CA
Practice Address - Zip Code:91311-2315
Practice Address - Country:US
Practice Address - Phone:818-998-6446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-16
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD28675261QD0000X
CAD27858261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental