=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346663473
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEXANDER A. GALVAN, DMD APC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/24/2014
-----------------------------------------------------
Last Update Date | 01/24/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1244 W BASE LINE RD SUITE E
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-8640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-873-3000
-----------------------------------------------------
Fax | 909-873-3008
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1244 W BASE LINE RD SUITE E
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-8640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-873-3000
-----------------------------------------------------
Fax | 909-873-3008
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DMD
-----------------------------------------------------
Name | DR. ALEXANDER GALVAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-873-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 45861
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------