1811017031 NPI number — DR. ANTOINE O. SOURIALLE D.D.S.

Table of content: (NPI 1760787949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811017031 NPI number — DR. ANTOINE O. SOURIALLE D.D.S.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SOURIALLE
Provider First Name:
ANTOINE
Provider Middle Name:
O.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.D.S.
Provider Gender Code:
M

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:
1811017031
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
399 E HIGHLAND AVE STE 120
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:
92404-3812
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-881-0645
Provider Business Mailing Address Fax Number:
909-881-4957

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
399 E HIGHLAND AVE STE 120
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92404-3812
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-881-0645
Provider Business Practice Location Address Fax Number:
909-881-4957
Provider Enumeration Date:
03/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  44093 , 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)

  • Identifier: 0010973 . This is a "ASSURANT HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0210745 . This is a "CIGNA HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 10490 . This is a "PACIFICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: P006271 . This is a "WELLPOINT DENTAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 01628 . This is a "WESTERN DENTAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 50755-1 . This is a "BLUE SHIELD" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 004239 . This is a "LIBERTY DENTAL HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 0004636 . This is a "MANAGED DENTAL CARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: DJ61 . This is a "SMILESAVER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 20088156 . This is a "PRIVIOUS EIN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 007367 . This is a "PMI" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 134921 . This is a "DHS HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 97036530 . This is a "SAFEGUARD HMO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: D44093 . This is a "DENT-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: F0275 . This is a "GOLDENWEST" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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