1104390079 NPI number — BRIDENT DENTAL ASSOCIATES PC

Table of content: (NPI 1104390079)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104390079 NPI number — BRIDENT DENTAL ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRIDENT DENTAL ASSOCIATES PC
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:
1104390079
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
530 S MAIN ST STE 600
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ORANGE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92868-4544
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-480-3000
Provider Business Mailing Address Fax Number:
714-571-6445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1173 EDGEBROOK DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77034-1862
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-595-8888
Provider Business Practice Location Address Fax Number:
713-595-8893
Provider Enumeration Date:
01/14/2019

Additional Information

Authorized Official

Authorized Official Last Name:
ZAMORA
Authorized Official First Name:
MARIBEL
Authorized Official Middle Name:
Authorized Official Title or Position:
ENROLLMENT COORDINATOR
Authorized Official Telephone Number:
714-571-3104

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: G60850 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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