=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851993307
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | P AND R MANAGEMENT
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/10/2020
-----------------------------------------------------
Last Update Date | 01/07/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27168 NEWPORT RD STE 3
-----------------------------------------------------
City | MENIFEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92584-7383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-672-9666
-----------------------------------------------------
Fax | 951-672-7666
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27168 NEWPORT RD STE 3
-----------------------------------------------------
City | MENIFEE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92584-7383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-672-9666
-----------------------------------------------------
Fax | 951-672-7666
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JOSEPH RENZI JR.
-----------------------------------------------------
Credential | MA, DDS
-----------------------------------------------------
Telephone | 951-672-9666
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------