MEDICARE: SYNERGY DENTAL MANAGEMENT, INC

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		CA

General Provider Information

NPI Number	:	1487066890
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SYNERGY DENTAL MANAGEMENT, INC

Provider Business Mailing Address
First Line	:	3229 SANTA ANITA AVE
Second Line	:	#B
City	:	EL MONTE
State	:	CA
Zip	:	91733-1359
Country	:	US
Telephone Number	:	626-800-7235
Fax Number	:	626-789-0288

Provider Business Practice Location Address
First Line	:	3229 SANTA ANITA AVE
Second Line	:	#B
City	:	EL MONTE
State	:	CA
Zip	:	91733-1359
Country	:	US
Telephone Number	:	626-800-7235
Fax Number	:	626-789-0288

Authorized Official
Title or Position	:	OWNER
Name	:	MR. CHRISTOPHER MACIAS
Credential	:
Telephone Number	:	626-800-7235

Provider Enumeration Date	:	05/21/2014
Last Update Date	:	05/21/2014

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