=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013273093
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AILEEN C LUNA DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2012
-----------------------------------------------------
Last Update Date | 04/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1301 W ARROW HWY STE 120
-----------------------------------------------------
City | SAN DIMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91773-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-592-8338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1301 W ARROW HWY STE 120
-----------------------------------------------------
City | SAN DIMAS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91773-2330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-592-8338
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. AILEEN CONTRERAS LUNA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-684-0123
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 50780
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------