Healthcare Provider Details

I. General information

NPI: 1497059166
Provider Name (Legal Business Name): HNC ORTHODONTIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2011
Last Update Date: 01/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26302 LA PAZ RD STE 202
MISSION VIEJO CA
92691-5328
US

IV. Provider business mailing address

26302 LA PAZ RD STE 202
MISSION VIEJO CA
92691-5328
US

V. Phone/Fax

Practice location:
  • Phone: 949-830-4101
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number56349
License Number StateCA

VIII. Authorized Official

Name: DR. SHANNON NISSEN
Title or Position: OWNER
Credential:
Phone: 949-830-4101