=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376197954
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PURECO DENTAL GROUP INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/31/2019
-----------------------------------------------------
Last Update Date | 01/23/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 485 E FOOTHILL BLVD STE E
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-3987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-256-0090
-----------------------------------------------------
Fax | 909-256-0092
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 485 E FOOTHILL BLVD STE E
-----------------------------------------------------
City | UPLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91786-3987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-256-0090
-----------------------------------------------------
Fax | 909-256-0092
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/ DENTIST
-----------------------------------------------------
Name | MARIO PURECO
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 909-256-0090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------