Provider Demographics
NPI:1720577570
Name:INDIAN HILLS DENTAL, AVILA DENTAL CORPORATION
Entity Type:Organization
Organization Name:INDIAN HILLS DENTAL, AVILA DENTAL CORPORATION
Other - Org Name:INDIAN HILLS DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:ANNETTE
Authorized Official - Last Name:AVILA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-361-0443
Mailing Address - Street 1:8300 LIMONITE AVE STE C
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-5174
Mailing Address - Country:US
Mailing Address - Phone:951-361-0443
Mailing Address - Fax:
Practice Address - Street 1:8300 LIMONITE AVE STE C
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-5174
Practice Address - Country:US
Practice Address - Phone:951-361-0443
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-08
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49460261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid