Healthcare Provider Details

I. General information

NPI: 1942437983
Provider Name (Legal Business Name): ASIL DENTAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2009
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

390 CAMINO DE ESTRELLA
SAN CLEMENTE CA
92672-4859
US

IV. Provider business mailing address

390 CAMINO DE ESTRELLA
SAN CLEMENTE CA
92672-4859
US

V. Phone/Fax

Practice location:
  • Phone: 949-481-2000
  • Fax: 949-481-2411
Mailing address:
  • Phone: 949-481-2000
  • Fax: 949-481-2411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number56645
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number49560
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number52200
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number52710
License Number StateCA

VIII. Authorized Official

Name: MRS. MARINA O ASIL
Title or Position: OFFICE MANAGER
Credential:
Phone: 949-481-2000