Provider Demographics
NPI:1942490602
Name:MID VALLEY DENTAL CARE-NORTHRIDGE
Entity type:Organization
Organization Name:MID VALLEY DENTAL CARE-NORTHRIDGE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER / PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TERENCE
Authorized Official - Middle Name:KIEN-WA
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:818-886-3500
Mailing Address - Street 1:19331 BUSINESS CENTER DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324
Mailing Address - Country:US
Mailing Address - Phone:818-886-3500
Mailing Address - Fax:818-886-1733
Practice Address - Street 1:19331 BUSINESS CENTER DRIVE
Practice Address - Street 2:SUITE 101
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91324
Practice Address - Country:US
Practice Address - Phone:818-886-3500
Practice Address - Fax:818-886-1733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
6389980001Medicare NSC