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General NPI Number Information
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NPI Number | 1801029681
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Entity Type | Organization
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Legal Business Name | CLINICA DENTAL FAMILIAR SAN JUDAS TADEO
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Dates
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Enumeration Date | 08/27/2009
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Last Update Date | 08/27/2009
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Provider Practice Location Address
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Address Line | 1245 N GROVE AVE STE C
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City | ONTARIO
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State | CA
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Zip | 91764-2557
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Country | US
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Telephone | 909-458-1068
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Fax | 909-988-0792
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Provider Business Mailing Address
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Address Line | 1245 N GROVE AVE STE C
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City | ONTARIO
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State | CA
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Zip | 91764-2557
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Country | US
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Telephone | 909-458-1068
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Fax | 909-988-0792
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Authorized Official
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Title or Position | BILLER
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Name | ELIZABETH DUARTE
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Credential |
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Telephone | 909-988-1800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 50895
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License Number State | CA
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