=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922861400
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RODERICK PANGILINAN DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/06/2024
-----------------------------------------------------
Last Update Date | 02/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 N IMPERIAL AVE STE F
-----------------------------------------------------
City | EL CENTRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92243-2338
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-353-1059
-----------------------------------------------------
Fax | 760-353-7378
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1098 SKYVIEW AVE
-----------------------------------------------------
City | EL CENTRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92243-9133
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-677-0598
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | D.D.S./OWNER
-----------------------------------------------------
Name | RODERICK PANGILINAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 619-677-0598
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------