=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134254279
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMARA CRANDALL ORTHODONTICS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2007
-----------------------------------------------------
Last Update Date | 04/21/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2710 N GRAND AVE
-----------------------------------------------------
City | SANTA ANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92705-8750
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-202-5648
-----------------------------------------------------
Fax | 949-932-0455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1516 CONTESSA
-----------------------------------------------------
City | IRVINE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92620-1732
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-239-5027
-----------------------------------------------------
Fax | 949-932-0455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ORTHODONTIST
-----------------------------------------------------
Name | DR. AMARA CRANDALL
-----------------------------------------------------
Credential | DDS, MSD
-----------------------------------------------------
Telephone | 714-202-5648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 38029
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------