Healthcare Provider Details

I. General information

NPI: 1962890632
Provider Name (Legal Business Name): HANAWALT DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2015
Last Update Date: 01/05/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 D ST
LA VERNE CA
91750-4416
US

IV. Provider business mailing address

2450 D ST
LA VERNE CA
91750-4416
US

V. Phone/Fax

Practice location:
  • Phone: 909-593-4581
  • Fax:
Mailing address:
  • Phone: 909-593-4581
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State

VIII. Authorized Official

Name: DR. ROGER M HANAWALT
Title or Position: OWNER
Credential: D.D.S
Phone: 909-593-4581