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General NPI Number Information
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NPI Number | 1467642280
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Entity Type | Organization
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Legal Business Name | PUENTE HILLS DENTAL GROUP
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Dates
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Enumeration Date | 07/27/2007
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Last Update Date | 07/27/2007
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Provider Practice Location Address
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Address Line | 1850 S AZUSA AVE STE 202
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City | HACIENDA HEIGHTS
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State | CA
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Zip | 91745-6853
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Country | US
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Telephone | 626-854-9530
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Fax |
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Provider Business Mailing Address
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Address Line | 1850 S AZUSA AVE STE 202
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City | HACIENDA HEIGHTS
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State | CA
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Zip | 91745-6853
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Country | US
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Telephone | 626-854-9530
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. EVANGELOS ROSSOPOULOS
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Credential | D.D.S.
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Telephone | 626-854-9530
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0700X
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Taxonomy Name | Prosthodontics
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License Number | 36605
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 31027
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License Number State | CA
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