Provider Demographics
NPI:1902952740
Name:WESTERN DENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:WESTERN DENTAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF INFORMATION OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:PREET
Authorized Official - Middle Name:
Authorized Official - Last Name:TAKKAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-571-3372
Mailing Address - Street 1:113 N MACLAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-2906
Mailing Address - Country:US
Mailing Address - Phone:818-365-8334
Mailing Address - Fax:818-898-3924
Practice Address - Street 1:113 N MACLAY AVE
Practice Address - Street 2:
Practice Address - City:SAN FERNANDO
Practice Address - State:CA
Practice Address - Zip Code:91340-2906
Practice Address - Country:US
Practice Address - Phone:818-365-8334
Practice Address - Fax:818-898-3924
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90179-07Medicaid