Healthcare Provider Details

I. General information

NPI: 1093126278
Provider Name (Legal Business Name): FAMILY DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/09/2014
Last Update Date: 05/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44558 10TH ST W
LANCASTER CA
93534-3333
US

IV. Provider business mailing address

355 E MONTANA ST
PASADENA CA
91104-1014
US

V. Phone/Fax

Practice location:
  • Phone: 661-723-1111
  • Fax:
Mailing address:
  • Phone: 626-344-5641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code292200000X
TaxonomyDental Laboratory
License Number
License Number State

VIII. Authorized Official

Name: LAMON BRANNER
Title or Position: DENTAL ASSISTANT
Credential:
Phone: 626-344-5641