Basic Information
| Provider Information | |||||||||
| NPI: | 1487128054 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN DENTAL SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144803000 | ||||||||
| FaxNumber: | 7145716445 | ||||||||
| Practice Location | |||||||||
| Address1: | 902 E HAMMER LN | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952103027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099579500 | ||||||||
| FaxNumber: | 2099579508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2019 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | TAKKAR | ||||||||
| AuthorizedOfficialFirstName: | PREET | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF INFORMATION OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7145713372 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | G90179 | 05 | CA | MEDICAID |