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General NPI Number Information
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NPI Number | 1497003685
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Entity Type | Organization
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Legal Business Name | GLENDALE SURGICAL ASSOCIATES, LP
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Dates
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Enumeration Date | 08/21/2012
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Last Update Date | 08/21/2012
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Provider Practice Location Address
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Address Line | 11550 INDIAN HILLS RD STE 270
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City | MISSION HILLS
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State | CA
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Zip | 91345-1244
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Country | US
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Telephone | 818-365-5636
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Fax | 818-365-5639
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Provider Business Mailing Address
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Address Line | 11550 INDIAN HILLS RD STE 270
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City | MISSION HILLS
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State | CA
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Zip | 91345-1244
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Country | US
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Telephone | 818-365-5636
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Fax | 818-365-5639
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | DIANNE LAFAURIE
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Credential |
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Telephone | 818-241-4217
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 21413
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | OMS71
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | 37945
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number | OMS94
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License Number State | CA
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