Provider Demographics
NPI:1013134808
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:PRESIDENT CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LEONEED
Authorized Official - Middle Name:
Authorized Official - Last Name:GORDON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-273-1333
Mailing Address - Street 1:2205 E PALMDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-1316
Mailing Address - Country:US
Mailing Address - Phone:661-273-1333
Mailing Address - Fax:661-273-1687
Practice Address - Street 1:2205 E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-1316
Practice Address - Country:US
Practice Address - Phone:661-273-1333
Practice Address - Fax:661-273-1687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA329361223G0001X
CA432661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA43622OtherDENTIST
CA32936OtherDENTIST
CA=========OtherDENTAL CORPORATION