Healthcare Provider Details

I. General information

NPI: 1407309602
Provider Name (Legal Business Name): ECHARTE-RODRIGUEZ DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2016
Last Update Date: 07/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

546 W BADILLO ST STE E
COVINA CA
91722-3786
US

IV. Provider business mailing address

546 W BADILLO ST STE E
COVINA CA
91722-3786
US

V. Phone/Fax

Practice location:
  • Phone: 626-331-6666
  • Fax: 626-331-6660
Mailing address:
  • Phone: 626-331-6666
  • Fax: 626-331-6660

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number52379
License Number StateCA

VIII. Authorized Official

Name: DR. GONZALO ECHARTE
Title or Position: DOCTOR- OWNER
Credential: DDS
Phone: 626-331-6666