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General NPI Number Information
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NPI Number | 1396822029
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Entity Type | Organization
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Legal Business Name | RACHO NIGUEL DENTAL GROUP
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Dates
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Enumeration Date | 11/01/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 30140 TOWN CENTER DRIVE
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City | LAGUNA NIGUEL
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State | CA
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Zip | 92677
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Country | US
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Telephone | 949-249-4180
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Fax | 949-249-4185
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Provider Business Mailing Address
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Address Line | 828 EMERALD BAY
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City | LAGUNA BEACH
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State | CA
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Zip | 92651
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Country | US
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Telephone | 949-249-4180
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Fax |
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. GINA RENE MARTIN
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Credential |
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Telephone | 949-249-4180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 37868
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License Number State | CA
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