=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265173199
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIGLIAROLO CHEN CANLAS DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2022
-----------------------------------------------------
Last Update Date | 05/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 N CITRUS AVE STE A
-----------------------------------------------------
City | AZUSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91702-3957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-804-7715
-----------------------------------------------------
Fax | 626-507-6315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 N CITRUS AVE STE A
-----------------------------------------------------
City | AZUSA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91702-3957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-804-7715
-----------------------------------------------------
Fax | 626-507-6315
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MRS. ALENOR CANLAS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 626-804-7715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------