Provider Demographics
NPI:1801623871
Name:WONDERFUL LIFE DENTAL GROUP
Entity type:Organization
Organization Name:WONDERFUL LIFE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:
Authorized Official - Last Name:PAI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-757-9906
Mailing Address - Street 1:10470 FOOTHILL BLVD # 250
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-3754
Mailing Address - Country:US
Mailing Address - Phone:626-757-9906
Mailing Address - Fax:
Practice Address - Street 1:10470 FOOTHILL BLVD # 250
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-3754
Practice Address - Country:US
Practice Address - Phone:626-757-9906
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental