Healthcare Provider Details

I. General information

NPI: 1871858688
Provider Name (Legal Business Name): FAMILY DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 W 19TH ST SUITE C
COSTA MESA CA
92627-3517
US

IV. Provider business mailing address

516 W 17TH ST SUITE A
SANTA ANA CA
92706-3677
US

V. Phone/Fax

Practice location:
  • Phone: 714-722-9027
  • Fax: 714-722-9028
Mailing address:
  • Phone: 714-972-2606
  • Fax: 714-972-2607

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number55738
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number55738
License Number StateCA

VIII. Authorized Official

Name: LETICIA CAMACHO
Title or Position: PRESIDENR
Credential: D.D.S.
Phone: 714-972-2506