Basic Information
| Provider Information | |||||||||
| NPI: | 1326102823 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN DENTAL SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 51022 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900515322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144803000 | ||||||||
| FaxNumber: | 7145716445 | ||||||||
| Practice Location | |||||||||
| Address1: | 2626 MISSION ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4152857500 | ||||||||
| FaxNumber: | 4152859847 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2006 | ||||||||
| LastUpdateDate: | 03/20/2018 | ||||||||
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| AuthorizedOfficialLastName: | ZAMORA | ||||||||
| AuthorizedOfficialFirstName: | MARIBEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | ENROLLMENT COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7145713104 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | G90179-38 | 05 | CA | MEDICAID |