MEDICARE: PUENTE HILLS 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	1223P0700X	Prosthodontics	36605	CA
2	1223P0221X	Pediatric Dentistry	31027	CA

General Provider Information

NPI Number	:	1467642280
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PUENTE HILLS DENTAL GROUP

Provider Business Mailing Address
First Line	:	1850 S AZUSA AVE STE 202
Second Line	:
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-6853
Country	:	US
Telephone Number	:	626-854-9530
Fax Number	:

Provider Business Practice Location Address
First Line	:	1850 S AZUSA AVE STE 202
Second Line	:
City	:	HACIENDA HEIGHTS
State	:	CA
Zip	:	91745-6853
Country	:	US
Telephone Number	:	626-854-9530
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DR. EVANGELOS ROSSOPOULOS
Credential	:	D.D.S.
Telephone Number	:	626-854-9530

Provider Enumeration Date	:	07/27/2007
Last Update Date	:	07/27/2007

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