1316140213 NPI number — ESTAVILLO DENTAL CORPORATION

Table of content: (NPI 1316140213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316140213 NPI number — ESTAVILLO DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ESTAVILLO DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
TRI-VALLEY DENTAL CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316140213
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
39885 ALTA MURRIETA DR
Provider Second Line Business Mailing Address:
SUITE D-4
Provider Business Mailing Address City Name:
MURRIETA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92563-5438
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-304-7560
Provider Business Mailing Address Fax Number:
951-696-7780

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
39885 ALTA MURRIETA DR
Provider Second Line Business Practice Location Address:
SUITE D-4
Provider Business Practice Location Address City Name:
MURRIETA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92563-5438
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-304-7560
Provider Business Practice Location Address Fax Number:
951-696-7780
Provider Enumeration Date:
06/07/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ESTAVILLO
Authorized Official First Name:
NGOC-OANH
Authorized Official Middle Name:
NGO
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
951-304-7560

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  47966 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)