Healthcare Provider Details

I. General information

NPI: 1467642280
Provider Name (Legal Business Name): PUENTE HILLS DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2007
Last Update Date: 07/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 S AZUSA AVE STE 202
HACIENDA HEIGHTS CA
91745-6853
US

IV. Provider business mailing address

1850 S AZUSA AVE STE 202
HACIENDA HEIGHTS CA
91745-6853
US

V. Phone/Fax

Practice location:
  • Phone: 626-854-9530
  • Fax:
Mailing address:
  • Phone: 626-854-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number31027
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number36605
License Number StateCA

VIII. Authorized Official

Name: DR. EVANGELOS ROSSOPOULOS
Title or Position: OWNER
Credential: D.D.S.
Phone: 626-854-9530