=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124427620
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONRISSA DENTAL OFFICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/20/2014
-----------------------------------------------------
Last Update Date | 08/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 827 W VALLEY BLVD
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-514-0555
-----------------------------------------------------
Fax | 909-514-0556
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 827 W VALLEY BLVD
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-2001
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-514-0555
-----------------------------------------------------
Fax | 909-514-0556
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. GEORGE VALDEZ
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 909-514-0555
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 31542
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------