1417142050 NPI number — VANOWEN DENTAL CENTER

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 1417142050 NPI number — VANOWEN DENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANOWEN DENTAL CENTER
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:
1417142050
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/06/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6931 VAN NUYS BLVD STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAN NUYS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91405-3937
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-988-8080
Provider Business Mailing Address Fax Number:
818-988-8168

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6931 VAN NUYS BLVD STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAN NUYS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91405-3937
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-988-8080
Provider Business Practice Location Address Fax Number:
818-988-8168
Provider Enumeration Date:
09/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SUTANTO
Authorized Official First Name:
YENI
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS PARTNER
Authorized Official Telephone Number:
818-988-8080

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  B39212 , 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: G90871-01 . This is a "DENTICAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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