Healthcare Provider Details

I. General information

NPI: 1942490602
Provider Name (Legal Business Name): MID VALLEY DENTAL CARE-NORTHRIDGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2007
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19331 BUSINESS CENTER DRIVE SUITE 101
NORTHRIDGE CA
91324
US

IV. Provider business mailing address

19331 BUSINESS CENTER DRIVE SUITE 101
NORTHRIDGE CA
91324
US

V. Phone/Fax

Practice location:
  • Phone: 818-886-3500
  • Fax: 818-886-1733
Mailing address:
  • Phone: 818-886-3500
  • Fax: 818-886-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TERENCE KIEN-WA LAU
Title or Position: OWNER / PARTNER
Credential: D.D.S
Phone: 818-886-3500