Basic Information
Provider Information | |||||||||
NPI: | 1912488362 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WESTERN DENTAL SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 530 S MAIN ST | ||||||||
Address2: |   | ||||||||
City: | ORANGE | ||||||||
State: | CA | ||||||||
PostalCode: | 928684525 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144803000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2004 W AVENUE J | ||||||||
Address2: |   | ||||||||
City: | LANCASTER | ||||||||
State: | CA | ||||||||
PostalCode: | 935365913 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6619491970 | ||||||||
FaxNumber: | 6619497844 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/23/2018 | ||||||||
LastUpdateDate: | 05/14/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TAKKAR | ||||||||
AuthorizedOfficialFirstName: | PREET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF INFORMATION OFFICER | ||||||||
AuthorizedOfficialTelephone: | 7145713372 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
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 |