Provider Demographics
NPI:1912304619
Name:MAI DENTAL CORPORATION
Entity Type:Organization
Organization Name:MAI DENTAL CORPORATION
Other - Org Name:ALICIA PARKWAY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DMD/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:VU
Authorized Official - Last Name:MAI
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:949-587-3010
Mailing Address - Street 1:25401 ALICIA PKWY STE J
Mailing Address - Street 2:
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-4958
Mailing Address - Country:US
Mailing Address - Phone:949-587-3010
Mailing Address - Fax:
Practice Address - Street 1:25401 ALICIA PKWY STE J
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4958
Practice Address - Country:US
Practice Address - Phone:949-587-3010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-24
Last Update Date:2014-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA638791223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty