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General NPI Number Information
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NPI Number | 1275772634
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Entity Type | Organization
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Legal Business Name | HACIENDA DENTAL
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Dates
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Enumeration Date | 02/09/2009
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Last Update Date | 02/09/2009
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Provider Practice Location Address
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Address Line | 1507 PANAMA LANE 102
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City | BAKERSFIELD
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State | CA
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Zip | 93307
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Country | US
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Telephone | 661-398-5555
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Fax | 661-398-5510
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Provider Business Mailing Address
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Address Line | 4022 NILES ST
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City | BAKERSFIELD
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State | CA
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Zip | 93306-4630
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Country | US
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Telephone | 661-871-3736
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Fax | 661-871-7417
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MYRNA VELASQUEZ
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Credential |
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Telephone | 661-871-3736
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 33020
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License Number State | CA
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