Provider Demographics
NPI:1790999506
Name:MISSION DENTAL CENTER
Entity type:Organization
Organization Name:MISSION DENTAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OPHELIA
Authorized Official - Middle Name:GARCIA-
Authorized Official - Last Name:ADEMCZUK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-681-6611
Mailing Address - Street 1:8992 MISSION BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92509-2874
Mailing Address - Country:US
Mailing Address - Phone:951-681-6611
Mailing Address - Fax:951-681-6611
Practice Address - Street 1:8992 MISSION BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92509-2874
Practice Address - Country:US
Practice Address - Phone:951-681-6611
Practice Address - Fax:951-681-6611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2007-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36540302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization