Healthcare Provider Details

I. General information

NPI: 1134253339
Provider Name (Legal Business Name): LOMA LINDA UNIVERSITY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 03/18/2020
Certification Date: 03/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11092 ANDERSON STREET
LOMA LINDA CA
92354
US

IV. Provider business mailing address

11092 ANDERSON STREET
LOMA LINDA CA
92354
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4613
  • Fax: 909-558-4192
Mailing address:
  • Phone: 909-558-4613
  • Fax: 909-558-4192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number2055
License Number StateCA

VIII. Authorized Official

Name: MR. RODNEY DALE NEAL
Title or Position: VICE PRESIDENT
Credential:
Phone: 909-558-4543