MEDICARE: DIANE BOVAL DDS A PROFESSIONAL DENTAL CORP

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

General Provider Information

NPI Number	:	1659120921
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIANE BOVAL DDS A PROFESSIONAL DENTAL CORP

Provider Business Mailing Address
First Line	:	901 W. WHITTIER BLVD
Second Line	:
City	:	LA HABRA
State	:	CA
Zip	:	90631-3742
Country	:	US
Telephone Number	:	562-356-0948
Fax Number	:	866-817-3581

Provider Business Practice Location Address
First Line	:	29861 SANTA MARGARITA PARKWAY, SUITE A
Second Line	:
City	:	RANCHO SANTA MARGARITA
State	:	CA
Zip	:	92688-3624
Country	:	US
Telephone Number	:	949-773-4421
Fax Number	:	866-817-3581

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	ALAN BOVAL
Credential	:
Telephone Number	:	562-356-0948

Provider Enumeration Date	:	05/17/2024
Last Update Date	:	05/17/2024

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