Provider Demographics
NPI:1386986362
Name:SPECIALTY DENTAL GROUP
Entity type:Organization
Organization Name:SPECIALTY DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JORGE
Authorized Official - Middle Name:
Authorized Official - Last Name:OSORIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-948-7213
Mailing Address - Street 1:1777 N BELLFLOWER BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90815-4019
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1777 N BELLFLOWER BLVD STE 102
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90815-4019
Practice Address - Country:US
Practice Address - Phone:909-948-7211
Practice Address - Fax:909-948-7213
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-18
Last Update Date:2013-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X, 1223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty