Healthcare Provider Details

I. General information

NPI: 1174592372
Provider Name (Legal Business Name): TRENT HOWARD WESTERNOFF DDS DMD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 10/30/2024
Certification Date: 10/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30190 TOWN CENTER DRIVE SUITE B
LAGUNA NIGUEL CA
92677
US

IV. Provider business mailing address

30190 TOWN CENTER DRIVE SUITE B
LAGUNA NIGUEL CA
92677
US

V. Phone/Fax

Practice location:
  • Phone: 949-363-2540
  • Fax: 949-363-3352
Mailing address:
  • Phone: 949-363-2540
  • Fax: 949-363-3352

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number55703
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License NumberM0604
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19775
License Number StateMA
# 4
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number22087
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: