MEDICARE: LLU FACULTY DENTAL OFFICE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QD0000X	Dental Clinic/Center	7547	CA

General Provider Information

NPI Number	:	1134358815
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LLU FACULTY DENTAL OFFICE

Provider Business Mailing Address
First Line	:	1102 ANDERSTON ST
Second Line	:
City	:	LOMA LINDA
State	:	CA
Zip	:	92350-0001
Country	:	US
Telephone Number	:	909-558-8620
Fax Number	:	909-558-4192

Provider Business Practice Location Address
First Line	:	159 W HOSPITALITY LN
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3346
Country	:	US
Telephone Number	:	909-558-4660
Fax Number	:	909-558-0689

Authorized Official
Title or Position	:	VICE CHANCELOR, FINANCIAL AFFAIRS
Name	:	MR. VERLON WAYNE STRAUSS
Credential	:
Telephone Number	:	909-558-4611

Provider Enumeration Date	:	07/02/2009
Last Update Date	:	11/10/2010

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