Healthcare Provider Details

I. General information

NPI: 1548540552
Provider Name (Legal Business Name): VALLEY ACE DENTAL GROUP JOINT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2011
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8345 RESEDA BLVD STE 101
NORTHRIDGE CA
91324-4648
US

IV. Provider business mailing address

8345 RESEDA BLVD STE 101
NORTHRIDGE CA
91324-4648
US

V. Phone/Fax

Practice location:
  • Phone: 818-576-9990
  • Fax: 818-576-9993
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number54241
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MINDY PARK
Title or Position: GENERAL DENTIST
Credential: DDS
Phone: 818-576-9990