Healthcare Provider Details

I. General information

NPI: 1235679804
Provider Name (Legal Business Name): ASSISTANCE LEAGUE OF NEWPORT MESA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2017
Last Update Date: 03/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2220 FAIRVIEW RD
COSTA MESA CA
92627-1624
US

IV. Provider business mailing address

2220 FAIRVIEW RD
COSTA MESA CA
92627-1624
US

V. Phone/Fax

Practice location:
  • Phone: 949-645-2882
  • Fax:
Mailing address:
  • Phone: 949-645-2882
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MS. BARBARA MULLER MABERRY
Title or Position: PRESIDENT
Credential:
Phone: 949-645-2882