Healthcare Provider Details

I. General information

NPI: 1417381799
Provider Name (Legal Business Name): AMERICAN DENTAL IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2013
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3007 HUNTINGTON DR STE 201
PASADENA CA
91107-5522
US

IV. Provider business mailing address

3007 HUNTINGTON DR STE 201
PASADENA CA
91107-5522
US

V. Phone/Fax

Practice location:
  • Phone: 626-577-7770
  • Fax: 626-577-7777
Mailing address:
  • Phone: 626-577-7770
  • Fax: 626-577-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number55788
License Number StateCA

VIII. Authorized Official

Name: DR. JENNIFER CHA
Title or Position: OWNER
Credential: DMD, MS
Phone: 626-577-7770