1427675412 NPI number — FELDKAMP CAL SELECT DENTAL GROUP, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427675412 NPI number — FELDKAMP CAL SELECT DENTAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FELDKAMP CAL SELECT DENTAL GROUP, INC.
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:
Provider Other Organization Name Type Code:
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:
1427675412
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/08/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 10669
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92423-0669
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8325 HAVEN AVE STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RANCHO CUCAMONGA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91730-3894
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-332-6980
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/25/2020

Additional Information

Authorized Official

Authorized Official Last Name:
FELDKAMP III
Authorized Official First Name:
IRVING
Authorized Official Middle Name:
MOORE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
909-332-6980

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1982016838 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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