Healthcare Provider Details

I. General information

NPI: 1831455815
Provider Name (Legal Business Name): PREMIER ORTHODONTIC SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2012
Last Update Date: 04/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 SOLAR DR SUITE 200
OXNARD CA
93036-2661
US

IV. Provider business mailing address

2100 SOLAR DR SUITE 200
OXNARD CA
93036-2661
US

V. Phone/Fax

Practice location:
  • Phone: 805-485-1111
  • Fax: 805-981-7050
Mailing address:
  • Phone: 805-485-1111
  • Fax: 805-981-7050

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number46858
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number36249
License Number StateCA

VIII. Authorized Official

Name: DR. PAGE HUDSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 805-485-1111