Provider Demographics
NPI:1134358815
Name:LLU FACULTY DENTAL OFFICE
Entity type:Organization
Organization Name:LLU FACULTY DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE CHANCELOR, FINANCIAL AFFAIRS
Authorized Official - Prefix:MR
Authorized Official - First Name:VERLON
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:STRAUSS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-558-4611
Mailing Address - Street 1:1102 ANDERSTON ST
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-0001
Mailing Address - Country:US
Mailing Address - Phone:909-558-8620
Mailing Address - Fax:909-558-4192
Practice Address - Street 1:159 W HOSPITALITY LN
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3346
Practice Address - Country:US
Practice Address - Phone:909-558-4660
Practice Address - Fax:909-558-0689
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LOMA LINDA UNIVERSITY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-02
Last Update Date:2010-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7547261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABY004AMedicare PIN