=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710248364
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LIBERTY VILLAGE DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2012
-----------------------------------------------------
Last Update Date | 05/30/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13790 BEAR VALLEY RD E5
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-8699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-955-2273
-----------------------------------------------------
Fax | 760-955-0034
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 13790 BEAR VALLEY RD E5
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-8699
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-955-2273
-----------------------------------------------------
Fax | 760-955-0034
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MINDY TORRES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 760-955-2273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 35018
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------