=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659613792
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | E.C.GALVAN DMD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2013
-----------------------------------------------------
Last Update Date | 03/26/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1674 N SHORELINE BLVD STE. 126
-----------------------------------------------------
City | MOUNTAIN VIEW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94043-1374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-968-6141
-----------------------------------------------------
Fax | 650-968-6299
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1674 N SHORELINE BLVD STE. 126
-----------------------------------------------------
City | MOUNTAIN VIEW
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94043-1374
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-968-6141
-----------------------------------------------------
Fax | 650-968-6299
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. EVELYN CRUZ GALVAN
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 951-453-0024
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 39406
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------