Basic Information
| Provider Information | |||||||||
| NPI: | 1518698836 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDENT DDS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 530 S MAIN ST STE 600 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684544 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145713104 | ||||||||
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| Practice Location | |||||||||
| Address1: | 226 FLUOR DANIEL DR | ||||||||
| Address2: | |||||||||
| City: | SUGAR LAND | ||||||||
| State: | TX | ||||||||
| PostalCode: | 774794073 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2812422040 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2022 | ||||||||
| LastUpdateDate: | 06/17/2022 | ||||||||
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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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| NPICertificationDate: | 06/17/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist |
ID Information
| ID | Type | State | Issuer | Description | G60850 | 05 | TX | MEDICAID |