Healthcare Provider Details

I. General information

NPI: 1134332703
Provider Name (Legal Business Name): MONTCLAIR PLAZA DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2007
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5182 N MONTCLAIR PLAZA LN
MONTCLAIR CA
91763-1515
US

IV. Provider business mailing address

8660 CENTRAL AVE
MONTCLAIR CA
91763-1692
US

V. Phone/Fax

Practice location:
  • Phone: 909-626-3566
  • Fax: 909-626-6112
Mailing address:
  • Phone: 909-920-0696
  • Fax: 909-920-0517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: VIJAY B PATEL
Title or Position: OWNER/DDS
Credential:
Phone: 909-920-0696