MEDICARE: JUAN ANTONIO TREJO CANCHOLA 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	61049	CA

General Provider Information

NPI Number	:	1689039570
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JUAN ANTONIO TREJO CANCHOLA DENTAL CORP

Provider Business Mailing Address
First Line	:	9867 MAGNOLIA AVENUE
Second Line	:	SUITE E
City	:	RIVERSIDE
State	:	CA
Zip	:	92503
Country	:	US
Telephone Number	:	951-352-2112
Fax Number	:	951-352-2088

Provider Business Practice Location Address
First Line	:	23030 LAKE FOREST DR
Second Line	:	SUITE 201
City	:	LAGUNA HILLS
State	:	CA
Zip	:	92653-1331
Country	:	US
Telephone Number	:	949-305-8242
Fax Number	:	949-305-8238

Authorized Official
Title or Position	:	OWNER
Name	:	MR. JUAN A TREJO CANCHOLA
Credential	:
Telephone Number	:	951-842-0803

Provider Enumeration Date	:	12/21/2015
Last Update Date	:	12/21/2015

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