Provider Demographics
NPI:1356507800
Name:VICTOR VALLEY COMMUNITY DENTAL SERVICE PROGRAM
Entity type:Organization
Organization Name:VICTOR VALLEY COMMUNITY DENTAL SERVICE PROGRAM
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:LINDSAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:760-951-9181
Mailing Address - Street 1:14357 SEVENTH ST
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4209
Mailing Address - Country:US
Mailing Address - Phone:760-951-9181
Mailing Address - Fax:760-951-9308
Practice Address - Street 1:14357 SEVENTH ST
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4209
Practice Address - Country:US
Practice Address - Phone:760-951-9181
Practice Address - Fax:760-951-9308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA173941223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty