MEDICARE: CAMARRILLO SPRINGS 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	122300000X	Dentist	20546	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B20546-11	OTHER	CA	DENTICAL

General Provider Information

NPI Number	:	1538451273
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMARRILLO SPRINGS DENTAL GROUP

Provider Business Mailing Address
First Line	:	816 CAMARILLO SPRINGS RD
Second Line	:	SUITE #L
City	:	CAMARILLO
State	:	CA
Zip	:	93012-9441
Country	:	US
Telephone Number	:	805-388-3008
Fax Number	:	805-388-0062

Provider Business Practice Location Address
First Line	:	816 CAMARILLO SPRINGS RD
Second Line	:	SUITE #L
City	:	CAMARILLO
State	:	CA
Zip	:	93012-9441
Country	:	US
Telephone Number	:	805-388-3008
Fax Number	:	805-388-0062

Authorized Official
Title or Position	:	MANAGER
Name	:	YVONNE LOPEZ
Credential	:
Telephone Number	:	805-388-3008

Provider Enumeration Date	:	05/13/2011
Last Update Date	:	05/13/2011

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