Provider Demographics
NPI:1124547310
Name:IRVINE SPECTRUM DENTAL
Entity type:Organization
Organization Name:IRVINE SPECTRUM DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:CHARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:TONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-387-6418
Mailing Address - Street 1:9070 IRVINE CENTER DR STE 130
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-4690
Mailing Address - Country:US
Mailing Address - Phone:949-387-6418
Mailing Address - Fax:
Practice Address - Street 1:9070 IRVINE CENTER DR STE 130
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-4690
Practice Address - Country:US
Practice Address - Phone:949-387-6418
Practice Address - Fax:949-387-6419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45069261QD0000X
CA33186261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental