=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336542000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MOBILE DENTAL CLEANING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/08/2014
-----------------------------------------------------
Last Update Date | 10/08/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14 PASEO LUNA
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-697-7303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14 PASEO LUNA
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-697-7303
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MARY ANN MCCONNELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 949-697-7373
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 124Q00000X
-----------------------------------------------------
Taxonomy Name | Dental Hygienist
-----------------------------------------------------
License Number | HAP 229
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------