1366701096 NPI number — LANCE RYGG PROFESSIONAL DENTAL CORPORATION

Table of content: (NPI 1366701096)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366701096 NPI number — LANCE RYGG PROFESSIONAL DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LANCE RYGG PROFESSIONAL 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:
MISSION VALLEY DENTISTS
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:
1366701096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2860 MICHELLE DRIVE 2ND FLOOR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92606
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-368-2077
Provider Business Mailing Address Fax Number:
714-368-2092

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5638 MISSION CENTER RD
Provider Second Line Business Practice Location Address:
SUITE 107
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-4348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-220-0159
Provider Business Practice Location Address Fax Number:
619-220-0162
Provider Enumeration Date:
05/15/2012

Additional Information

Authorized Official

Authorized Official Last Name:
RYGG
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
C
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
619-220-0159

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  30251 , 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)





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