Provider Demographics
NPI:1063670768
Name:MISSION VIEJO DENTAL ASSOCIATES
Entity type:Organization
Organization Name:MISSION VIEJO DENTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:W
Authorized Official - Last Name:STALCUP
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-586-6200
Mailing Address - Street 1:25522 MARGUERITE PKWY
Mailing Address - Street 2:#100
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92692
Mailing Address - Country:US
Mailing Address - Phone:949-586-6200
Mailing Address - Fax:949-586-2791
Practice Address - Street 1:25522 MARGUERITE PARKWAY
Practice Address - Street 2:#100
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92692
Practice Address - Country:US
Practice Address - Phone:949-586-6200
Practice Address - Fax:949-586-2791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-29
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20049261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental