Healthcare Provider Details

I. General information

NPI: 1578051488
Provider Name (Legal Business Name): VIGLIAROLO DDS DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2018
Last Update Date: 04/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 S GLENDORA AVE STE A
WEST COVINA CA
91790-3042
US

IV. Provider business mailing address

266 S GLENDORA AVE STE A
WEST COVINA CA
91790-3042
US

V. Phone/Fax

Practice location:
  • Phone: 626-653-9276
  • Fax: 626-653-9814
Mailing address:
  • Phone: 626-653-9276
  • Fax: 626-653-9814

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59228
License Number StateCA

VIII. Authorized Official

Name: LUIS JAVIER VIGLIAROLO
Title or Position: PRESIDENT
Credential: DDS
Phone: 626-653-9276