Healthcare Provider Details

I. General information

NPI: 1740476316
Provider Name (Legal Business Name): WESTERN DENTAL SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2313 N CORRAL HOLLOW RD
TRACY CA
95376-9401
US

IV. Provider business mailing address

530 S MAIN ST
ORANGE CA
92868-4525
US

V. Phone/Fax

Practice location:
  • Phone: 209-832-9530
  • Fax: 209-832-9746
Mailing address:
  • Phone: 714-480-3000
  • Fax: 714-571-3560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARINA KING
Title or Position: PPO COORDINATOR
Credential:
Phone: 714-480-3000