Healthcare Provider Details

I. General information

NPI: 1902455694
Provider Name (Legal Business Name): HOSPITALITY DENTAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 W HOSPITALITY LN STE 14
SAN BERNARDINO CA
92408-3329
US

IV. Provider business mailing address

PO BOX 10669
SAN BERNARDINO CA
92423-0669
US

V. Phone/Fax

Practice location:
  • Phone: 909-888-7817
  • Fax: 909-495-1315
Mailing address:
  • Phone: 909-723-1044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: JOSUE MORAN
Title or Position: DIRECTOR OF ADMINISTRATIVE SERVICES
Credential:
Phone: 909-723-1044