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Provider Information for 1477074805

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: 1477074805

Calendar   Last Updated:  2019-03-21
  Certification Date: 


Name Value
NPI 1477074805
Enumeration Date 2017-07-06
NPI Type 1 - Individual
Sole Proprietor NO
Status Active
Mailing Address 32664 RITCHART CT
TEMECULA, CA 92592-3375
United States

Phone: 661-972-6923 | Fax:
View Map External Link
Primary Practice Address 26810 YNEZ CT STE E
TEMECULA, CA 92591-4691
United States

Phone: 209-533-9630 | Fax: 951-695-2223
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 101518