Healthcare Provider Details

I. General information

NPI: 1649340043
Provider Name (Legal Business Name): COMMUNITY DENTAL SERVICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15643 SHERMAN WAY
VAN NUYS CA
91406-4135
US

IV. Provider business mailing address

2 MACARTHUR PL SUITE 700
SANTA ANA CA
92707-5924
US

V. Phone/Fax

Practice location:
  • Phone: 818-786-2209
  • Fax: 818-786-8559
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MRS. ELAINE M SALCIDO
Title or Position: CONTRACT SUPERVISOR
Credential:
Phone: 714-708-5308