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NPI Code Detail

MEDICARE: BROCKTON DENTAL X-RAY LAB., INC.

MEDICARE: BROCKTON DENTAL X-RAY LAB., 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
1292200000XDental LaboratoryRHP7971CA
2292200000XDental LaboratoryRHP00050468CA

General Provider Information

NPI Number : 1467734491
Entity Type Code : Organization
Provider Name (Legal Business Name) : BROCKTON DENTAL X-RAY LAB., INC.
Provider Business Mailing Address
First Line : 6800 BROCKTON AVE STE 3
Second Line :
City : RIVERSIDE
State : CA
Zip : 92506-3810
Country : US
Telephone Number : 951-682-7505
Fax Number : 951-682-7549
Provider Business Practice Location Address
First Line : 6800 BROCKTON AVE STE 3
Second Line :
City : RIVERSIDE
State : CA
Zip : 92506-3810
Country : US
Telephone Number : 951-682-7505
Fax Number : 951-682-7549
Authorized Official
Title or Position : OWNER
Name : MICHAEL W. CARPENTER
Credential :
Telephone Number : 951-682-7505
Provider Enumeration Date : 09/15/2011
Last Update Date : 09/15/2011

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