Healthcare Provider Details

I. General information

NPI: 1780975755
Provider Name (Legal Business Name): WESTCOASTDENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2011
Last Update Date: 04/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15350 NORDHOFF STREET SUITE A
NORTH HILLS CA
91351
US

IV. Provider business mailing address

15350 NORDHOFF STREET SUITE A
NORTH HILLS CA
91343
US

V. Phone/Fax

Practice location:
  • Phone: 818-672-8228
  • Fax:
Mailing address:
  • Phone: 818-672-8228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MIGUEL REYES
Title or Position: CREDENTIALING
Credential:
Phone: 310-820-9933