Healthcare Provider Details

I. General information

NPI: 1497138317
Provider Name (Legal Business Name): DANIEL BACQUET D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17214 SATICOY ST
VAN NUYS CA
91406-2103
US

IV. Provider business mailing address

17250 RAYEN ST
SHERWOOD FOREST CA
91325-2919
US

V. Phone/Fax

Practice location:
  • Phone: 818-708-9909
  • Fax:
Mailing address:
  • Phone: 818-625-6044
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number64654
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: