Provider Demographics
NPI:1700926516
Name:HERCULES JOEL REAL, D.M.D., INC.
Entity Type:Organization
Organization Name:HERCULES JOEL REAL, D.M.D., INC.
Other - Org Name:REAL DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HERCULES
Authorized Official - Middle Name:J
Authorized Official - Last Name:REAL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:714-525-2888
Mailing Address - Street 1:1235 N. HARBOR BLVD.
Mailing Address - Street 2:SUITE 100
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92832-1323
Mailing Address - Country:US
Mailing Address - Phone:714-525-2888
Mailing Address - Fax:714-525-2123
Practice Address - Street 1:1235 N HARBOR BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1355
Practice Address - Country:US
Practice Address - Phone:714-525-2888
Practice Address - Fax:714-525-2123
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA48359261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG92806-01Medicare ID - Type UnspecifiedMEDI-CAL
CAG92806-01Medicaid
CAG92806-01OtherMEDI-CAL