Basic Information
| Provider Information | |||||||||
| NPI: | 1710030879 | ||||||||
| 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: | 7145713560 | ||||||||
| Practice Location | |||||||||
| Address1: | 1871 CAMDEN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN JOSE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 951242945 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4083775700 | ||||||||
| FaxNumber: | 4083770592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/19/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | KING | ||||||||
| AuthorizedOfficialFirstName: | MARINA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PPO COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 7144803000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | G90179-84 | 05 | CA | MEDICAID |