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Provider Information for 1376790907

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1376790907

Calendar   Last Updated:  2022-06-22
  Certification Date:  2022-06-22


Name Value
NPI 1376790907
Enumeration Date 2008-08-26
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 2860 MICHELLE 2ND FLOOR
IRVINE, CA 92606-1009
United States

Phone: 714-508-3600 | Fax: 714-368-2092
View Map External Link
Primary Practice Address 72027 HIGHWAY 111 SUITE C
RANCHO MIRAGE, CA 92270-4961
United States

Phone: 760-340-5155 | Fax: 760-340-1607
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 1223G0001X - Dentist General Practice CA 56741