Healthcare Provider Details

I. General information

NPI: 1659848208
Provider Name (Legal Business Name): PACIFIC DENTAL SERVICES FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2018
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4559 E. BELL ROAD, STE 106
PHOENIX AZ
85032
US

IV. Provider business mailing address

17000 RED HILL AVE
IRVINE CA
92614-5626
US

V. Phone/Fax

Practice location:
  • Phone: 714-845-8500
  • Fax: 303-952-0892
Mailing address:
  • Phone: 714-845-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: JACK DILLENBERG
Title or Position: OWNER
Credential:
Phone: 714-845-8500