MEDICARE: SAN ANTONIO DENTAL INC

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1063267748
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN ANTONIO DENTAL INC

Provider Business Mailing Address
First Line	:	PO BOX 7800
Second Line	:
City	:	HUNTINGTON BEACH
State	:	CA
Zip	:	92615-7800
Country	:	US
Telephone Number	:	714-717-9113
Fax Number	:	562-981-1438

Provider Business Practice Location Address
First Line	:	4342 ATLANTIC AVE STE A
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90807-2829
Country	:	US
Telephone Number	:	562-981-1437
Fax Number	:	562-981-1438

Authorized Official
Title or Position	:	PRESIDENT
Name	:	ELIZABETH P CASTANEDA
Credential	:	DMD
Telephone Number	:	562-981-1437

Provider Enumeration Date	:	04/17/2024
Last Update Date	:	04/17/2024

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Directions to “SAN ANTONIO DENTAL INC ” Practice Location

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