MEDICARE: WESTERN DENTAL SERVICES, 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
1	122300000X	Dentist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629542246
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WESTERN DENTAL SERVICES, INC.

Provider Business Mailing Address
First Line	:	530 S MAIN ST
Second Line	:
City	:	ORANGE
State	:	CA
Zip	:	92868-4525
Country	:	US
Telephone Number	:	714-480-3000
Fax Number	:	714-571-6445

Provider Business Practice Location Address
First Line	:	1600 TRAVIS BLVD
Second Line	:
City	:	FAIRFIELD
State	:	CA
Zip	:	94533-3429
Country	:	US
Telephone Number	:	707-429-4000
Fax Number	:	707-429-3012

Authorized Official
Title or Position	:	CHIEF INFORMATION OFFICER
Name	:	PREET TAKKAR
Credential	:
Telephone Number	:	714-571-3372

Provider Enumeration Date	:	01/16/2019
Last Update Date	:	03/28/2019

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Directions to “WESTERN DENTAL SERVICES, INC. ” Practice Location

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