Provider Demographics
NPI:1538451273
Name:CAMARRILLO SPRINGS DENTAL GROUP
Entity type:Organization
Organization Name:CAMARRILLO SPRINGS DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:
Authorized Official - Last Name:LOPEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-388-3008
Mailing Address - Street 1:816 CAMARILLO SPRINGS RD
Mailing Address - Street 2:SUITE #L
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-9441
Mailing Address - Country:US
Mailing Address - Phone:805-388-3008
Mailing Address - Fax:805-388-0062
Practice Address - Street 1:816 CAMARILLO SPRINGS RD
Practice Address - Street 2:SUITE #L
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-9441
Practice Address - Country:US
Practice Address - Phone:805-388-3008
Practice Address - Fax:805-388-0062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-13
Last Update Date:2011-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20546122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB20546-11OtherDENTICAL