1679086243 NPI number — SAN GABRIEL VALLEY ORAL AND FACIAL SURGERY

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 1679086243 NPI number — SAN GABRIEL VALLEY ORAL AND FACIAL SURGERY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SAN GABRIEL VALLEY ORAL AND FACIAL SURGERY
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:
6
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:
1679086243
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
126 S GLENDORA AVE STE 108
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WEST COVINA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91790-3047
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-966-8518
Provider Business Mailing Address Fax Number:
626-967-0990

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
126 S GLENDORA AVE STE 108
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEST COVINA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91790-3047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-966-8518
Provider Business Practice Location Address Fax Number:
626-967-0990
Provider Enumeration Date:
11/06/2017

Additional Information

Authorized Official

Authorized Official Last Name:
BOGLE
Authorized Official First Name:
PATTY
Authorized Official Middle Name:
K
Authorized Official Title or Position:
PRACTICE ADMINISTRATOR
Authorized Official Telephone Number:
626-966-8518

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  40257 , 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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