Healthcare Provider Details

I. General information

NPI: 1497914154
Provider Name (Legal Business Name): AMERICAN DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 08/18/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 N SUNSET AVE
WEST COVINA CA
91790-1652
US

IV. Provider business mailing address

436 N SUNSET AVE
WEST COVINA CA
91790-1652
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-7271
  • Fax: 626-337-8125
Mailing address:
  • Phone: 626-337-7271
  • Fax: 626-337-8125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number14915
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License NumberRDH16115
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number25306
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35537
License Number StateCA

VIII. Authorized Official

Name: DR. SERGE A PRESCOTT
Title or Position: DENTIST
Credential: DDS
Phone: 626-337-7271