Basic Information
Provider Information | |||||||||
NPI: | 1699874925 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NOSTI AND REAGAN DENTAL CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | SAN MARCOS DENTAL GROUP | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2860 MICHELLE | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | IRVINE | ||||||||
State: | CA | ||||||||
PostalCode: | 926061009 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7145083600 | ||||||||
FaxNumber: | 7143682092 | ||||||||
Practice Location | |||||||||
Address1: | 709 CENTER DR | ||||||||
Address2: | STE. 101 | ||||||||
City: | SAN MARCOS | ||||||||
State: | CA | ||||||||
PostalCode: | 920693536 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7145083600 | ||||||||
FaxNumber: | 7143682092 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/22/2006 | ||||||||
LastUpdateDate: | 10/22/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REAGAN | ||||||||
AuthorizedOfficialFirstName: | DARIN | ||||||||
AuthorizedOfficialMiddleName: | S | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER DDS | ||||||||
AuthorizedOfficialTelephone: | 7607462045 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | DDS | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.