=====================================================
General NPI Number Information
=====================================================
NPI Number | 1609358845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARTEAGA DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2018
-----------------------------------------------------
Last Update Date | 09/04/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 494 S RANCHO AVE
-----------------------------------------------------
City | SAN BERNARDINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92410-2144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-875-8930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 228 W BASE LINE RD
-----------------------------------------------------
City | RIALTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92376-3306
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-875-8930
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANAMARIA ARTEAGA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 909-875-8930
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 48222
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------