Provider Demographics
NPI:1023405008
Name:MEDICAL CENTER DENTAL GROUP
Entity type:Organization
Organization Name:MEDICAL CENTER DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WADID
Authorized Official - Middle Name:ANTOINE
Authorized Official - Last Name:FATTOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:714-557-8492
Mailing Address - Street 1:11160 WARNER AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-4008
Mailing Address - Country:US
Mailing Address - Phone:714-557-8492
Mailing Address - Fax:
Practice Address - Street 1:11160 WARNER AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-4008
Practice Address - Country:US
Practice Address - Phone:714-557-8492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30544122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty