MEDICARE: A WESTFALL DENTAL CORPORATION

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
2	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1427530161
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A WESTFALL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	PO BOX 551167
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96155-1167
Country	:	US
Telephone Number	:	530-600-2835
Fax Number	:

Provider Business Practice Location Address
First Line	:	540 MAIN ST
Second Line	:
City	:	DIAMOND SPRINGS
State	:	CA
Zip	:	95619-9109
Country	:	US
Telephone Number	:	530-600-2835
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. APRIL LYN WESTFALL
Credential	:	DMD
Telephone Number	:	530-600-2835

Provider Enumeration Date	:	08/29/2018
Last Update Date	:	08/29/2018

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