=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396991295
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTERNATIONAL DENTAL PROVIDERS CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/11/2008
-----------------------------------------------------
Last Update Date | 08/11/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1594 WOODLARK CT
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91911-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-691-8180
-----------------------------------------------------
Fax | 619-691-1201
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1594 WOODLARK CT
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91911-5321
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-691-8180
-----------------------------------------------------
Fax | 619-691-1201
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANGEL SERRANO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 619-691-8180
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 512443
-----------------------------------------------------
License Number State | ZZ
-----------------------------------------------------