Healthcare Provider Details

I. General information

NPI: 1790123966
Provider Name (Legal Business Name): WESTCOAST DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12730 HAWTHORNE BLVD STE D
HAWTHORNE CA
90250-3919
US

IV. Provider business mailing address

12121 WILSHIRE BLVD STE 1111
LOS ANGELES CA
90025-1188
US

V. Phone/Fax

Practice location:
  • Phone: 310-644-4000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number25300
License Number StateCA

VIII. Authorized Official

Name: MR. MIGUEL REYES
Title or Position: CREDENTIALING
Credential:
Phone: 310-820-9933