Healthcare Provider Details

I. General information

NPI: 1922406883
Provider Name (Legal Business Name): WESTERN DENTAL SERVICE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/09/2014
Last Update Date: 12/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2094 E HIGHLAND AVE
SAN BERNARDINO CA
92404-4626
US

IV. Provider business mailing address

530 S MAIN ST
ORANGE CA
92868-4525
US

V. Phone/Fax

Practice location:
  • Phone: 909-388-2420
  • Fax: 909-388-2426
Mailing address:
  • Phone: 714-480-3000
  • Fax: 714-571-6445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MARIBEL ZAMORA
Title or Position: ENROLLMENT COORDINATOR
Credential:
Phone: 714-571-3104