=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033932363
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PREMIER PEDIATRIC DENTISTRY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/05/2024
-----------------------------------------------------
Last Update Date | 11/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24541 PACIFIC PARK DR STE 240
-----------------------------------------------------
City | ALISO VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92656-3050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-880-6683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24541 PACIFIC PARK DR STE 240
-----------------------------------------------------
City | ALISO VIEJO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92656-3050
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-880-6683
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | DAGGIANA L CORGNELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-880-6683
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------