=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588981229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ILAGAN DENTAL CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/20/2010
-----------------------------------------------------
Last Update Date | 04/20/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 556 S BRAND BLVD
-----------------------------------------------------
City | SAN FERNANDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91340-4002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-365-3004
-----------------------------------------------------
Fax | 818-365-7100
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 556 S BRAND BLVD
-----------------------------------------------------
City | SAN FERNANDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91340-4002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-365-3004
-----------------------------------------------------
Fax | 818-365-7100
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. MARIA ELOISA ILAGAN
-----------------------------------------------------
Credential | D.D.S
-----------------------------------------------------
Telephone | 818-365-3004
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302F00000X
-----------------------------------------------------
Taxonomy Name | Exclusive Provider Organization
-----------------------------------------------------
License Number | 46831
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------