Provider Demographics
NPI:1750576096
Name:RANCHO DENTAL OFFICE
Entity type:Organization
Organization Name:RANCHO DENTAL OFFICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FERNANDO
Authorized Official - Middle Name:J
Authorized Official - Last Name:VILLARROEL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-421-1555
Mailing Address - Street 1:2010 N RIVERSIDE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-4652
Mailing Address - Country:US
Mailing Address - Phone:909-421-1555
Mailing Address - Fax:909-421-1865
Practice Address - Street 1:2010 N RIVERSIDE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92377-4652
Practice Address - Country:US
Practice Address - Phone:909-421-1555
Practice Address - Fax:909-421-1865
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-10
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44377261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93878-01OtherDENTICAL