Provider Demographics
NPI:1457533663
Name:WEST COAST MAXILLOFACIAL IMAGING
Entity Type:Organization
Organization Name:WEST COAST MAXILLOFACIAL IMAGING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CLAUDETTE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BUEHLER
Authorized Official - Suffix:
Authorized Official - Credentials:DRT
Authorized Official - Phone:916-961-1032
Mailing Address - Street 1:7916 PEBBLE BEACH DR
Mailing Address - Street 2:204
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-7790
Mailing Address - Country:US
Mailing Address - Phone:916-961-1032
Mailing Address - Fax:916-961-5712
Practice Address - Street 1:7916 PEBBLE BEACH DR
Practice Address - Street 2:204
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7790
Practice Address - Country:US
Practice Address - Phone:916-961-1032
Practice Address - Fax:916-961-5712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-29
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARHP41025292200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes292200000XLaboratoriesDental Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACGP167321OtherCALIFORNIA CHILDRENS SERV