Healthcare Provider Details

I. General information

NPI: 1700626116
Provider Name (Legal Business Name): NORTH TUSTIN DENTAL SPECIALTY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2024
Last Update Date: 05/31/2024
Certification Date: 05/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18102 IRVINE BLVD STE 211
TUSTIN CA
92780-3414
US

IV. Provider business mailing address

1245 W HUNTINGTON DR STE 103
ARCADIA CA
91007-6384
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-2001
  • Fax:
Mailing address:
  • Phone: 626-898-9787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: MS. SHERLENE TING
Title or Position: ADMINISTRATOR
Credential:
Phone: 626-375-0656