MEDICARE: PLB CALUGCUGAN/LEGASPI DENTAL CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	40654	CA

General Provider Information

NPI Number	:	1003106717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLB CALUGCUGAN/LEGASPI DENTAL CENTER

Provider Business Mailing Address
First Line	:	8215 VAN NUYS BLVD STE 302
Second Line	:
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402-4838
Country	:	US
Telephone Number	:	818-786-7986
Fax Number	:

Provider Business Practice Location Address
First Line	:	8215 VAN NUYS BLVD STE 302
Second Line	:
City	:	PANORAMA CITY
State	:	CA
Zip	:	91402-4838
Country	:	US
Telephone Number	:	818-786-7986
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. RENATO LIMEN CALUGCUGAN
Credential	:	D.M.D.
Telephone Number	:	818-786-7986

Provider Enumeration Date	:	04/14/2011
Last Update Date	:	04/14/2011

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