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Provider Information for 1710049598

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: 1710049598

Calendar   Last Updated:  2007-07-08
  Certification Date: 


Name Value
NPI 1710049598
Enumeration Date 2006-12-15
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 2849 MUIR TRAIL DR
FULLERTON, CA 92833-5517
United States

Phone: 310-694-6156 | Fax:
View Map External Link
Primary Practice Address 81735 HIGHWAY 111, SUITE A
INDIO, CA 92201
United States

Phone: 760-391-4474 | Fax:
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 122300000X - Dentist CA 54475