Healthcare Provider Details

I. General information

NPI: 1376906974
Provider Name (Legal Business Name): WILLY VILLAGRAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 10/05/2020
Certification Date: 10/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21229 HAWTHORNE BLVD STE A
TORRANCE CA
90503-5501
US

IV. Provider business mailing address

308 S BUSH ST
ANAHEIM CA
92805-4129
US

V. Phone/Fax

Practice location:
  • Phone: 310-409-4265
  • Fax:
Mailing address:
  • Phone: 714-232-6769
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number72577
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: