Healthcare Provider Details

I. General information

NPI: 1427201151
Provider Name (Legal Business Name): PHILLIPS RANCH DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2008
Last Update Date: 10/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 VILLAGE LOOP RD B2
PHILLIPS RANCH CA
91766-4891
US

IV. Provider business mailing address

4 VILLAGE LOOP RD B2
PHILLIPS RANCH CA
91766-4891
US

V. Phone/Fax

Practice location:
  • Phone: 909-620-0321
  • Fax: 909-620-0324
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number24452
License Number StateCA

VIII. Authorized Official

Name: MRS. JODIE ANN RAMIREZ
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 909-620-0321