Provider Demographics
NPI:1700919974
Name:VALENCIA CHILDREN'S DENTAL GROUP
Entity Type:Organization
Organization Name:VALENCIA CHILDREN'S DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROSE
Authorized Official - Middle Name:E
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:661-294-1800
Mailing Address - Street 1:27885 SMYTH DR
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-4011
Mailing Address - Country:US
Mailing Address - Phone:661-294-1800
Mailing Address - Fax:661-294-9774
Practice Address - Street 1:27885 SMYTH DR
Practice Address - Street 2:
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-4011
Practice Address - Country:US
Practice Address - Phone:661-294-1800
Practice Address - Fax:661-294-9774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390251223P0221X
CA412871223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherUNITED CONCORDIA
CA=========OtherBLUE CROSS
CA=========OtherMET LIFE
CA=========OtherAETNA
CA=========OtherEBA
CA=========OtherASSURANT EMPLOYEE BENEFIT
CA=========OtherCONNECTICUT GENERAL
CA=========OtherWASHINGTON DENTAL SERVICE
CA=========OtherUNITED HEALTHCARE
CA=========OtherANTHEM
CA=========OtherBLUE SHIELD
CA=========OtherPACIFIC CARE
CA=========OtherDELTA DENTAL
CA=========OtherDELTA USA
CA=========OtherCORE SOURCE
CA=========OtherGENWORTH FINANCIAL
CA=========OtherGOLDEN WEST
CA=========OtherFORTIS
CA=========OtherGUARDIAN
CA=========OtherCARPENTERS HEALTH & WELFA