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General NPI Number Information
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NPI Number | 1750575403
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Entity Type | Organization
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Legal Business Name | PACIFIC DENTAL CLINIC
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Dates
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Enumeration Date | 09/05/2007
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Last Update Date | 09/05/2007
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Provider Practice Location Address
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Address Line | 1201 N EUCLID ST
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City | ANAHEIM
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State | CA
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Zip | 92801-1954
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Country | US
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Telephone | 714-817-8345
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Fax | 714-224-7688
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Provider Business Mailing Address
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Address Line | 1201 N EUCLID ST
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City | ANAHEIM
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State | CA
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Zip | 92801-1954
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Country | US
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Telephone | 714-817-8345
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Fax | 714-224-7688
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Authorized Official
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Title or Position | DENTIST
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Name | JORGE LUIS GERONIMO
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Credential | DDS
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Telephone | 714-817-8345
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | 47897
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License Number State | CA
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