Healthcare Provider Details

I. General information

NPI: 1457511388
Provider Name (Legal Business Name): SUNSHINEDENTALGROUPOF JORGEANGEL VILLASENORDDSDENTALCORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4161 TYLER AVE
EL MONTE CA
91731-1966
US

IV. Provider business mailing address

4161 TYLER AVE
EL MONTE CA
91731-1966
US

V. Phone/Fax

Practice location:
  • Phone: 626-579-4274
  • Fax:
Mailing address:
  • Phone: 626-579-4274
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number
License Number State

VIII. Authorized Official

Name: JORGE A VILLASENOR
Title or Position: OWNER
Credential:
Phone: 626-579-4274