MEDICARE: SPECIALTY DENTAL GROUP

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	1223E0200X	Endodontics		CA
2	122300000X	Dentist		CA

General Provider Information

NPI Number	:	1386986362
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPECIALTY DENTAL GROUP

Provider Business Mailing Address
First Line	:	1777 N BELLFLOWER BLVD STE 102
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-4019
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1777 N BELLFLOWER BLVD STE 102
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90815-4019
Country	:	US
Telephone Number	:	909-948-7211
Fax Number	:	909-948-7213

Authorized Official
Title or Position	:	PARTNER
Name	:	JORGE OSORIO
Credential	:
Telephone Number	:	909-948-7213

Provider Enumeration Date	:	03/18/2013
Last Update Date	:	03/18/2013

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