Basic Information
| Provider Information | |||||||||
| NPI: | 1659442838 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY DENTAL SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SMILECARE DENTAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MACARTHUR PL | ||||||||
| Address2: | SUITE 700 | ||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927075924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147085308 | ||||||||
| FaxNumber: | 7147085399 | ||||||||
| Practice Location | |||||||||
| Address1: | 12233 CENTRAL AVE | ||||||||
| Address2: | |||||||||
| City: | CHINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917102423 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096280208 | ||||||||
| FaxNumber: | 9096273372 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SALCIDO | ||||||||
| AuthorizedOfficialFirstName: | ELAINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTRACT SUPERVISOR | ||||||||
| AuthorizedOfficialTelephone: | 7147085308 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.