MEDICARE: CROWN CONCORDIA DENTAL NETWORK

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	302R00000X	Health Maintenance Organization	44169	CA

General Provider Information

NPI Number	:	1427237577
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROWN CONCORDIA DENTAL NETWORK

Provider Business Mailing Address
First Line	:	290 W ORANGE SHOW RD
Second Line	:	SUITE 105
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3345
Country	:	US
Telephone Number	:	909-885-7600
Fax Number	:	909-885-7612

Provider Business Practice Location Address
First Line	:	290 W ORANGE SHOW RD
Second Line	:	SUITE 105
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92408-3345
Country	:	US
Telephone Number	:	909-885-7600
Fax Number	:	909-885-7612

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. WAGNER DE LUCA FARIA
Credential	:	DDS
Telephone Number	:	909-885-7600

Provider Enumeration Date	:	10/25/2007
Last Update Date	:	10/25/2007

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