Healthcare Provider Details

I. General information

NPI: 1710161880
Provider Name (Legal Business Name): THE CHILDREN'S DENTAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 01/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 FALLS CANYON ROAD
AVALON CA
90704
US

IV. Provider business mailing address

200 FALLS CANYON ROAD
AVALON CA
90704
US

V. Phone/Fax

Practice location:
  • Phone: 310-510-8287
  • Fax:
Mailing address:
  • Phone: 310-510-8287
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN BLAKE
Title or Position: DENTAL DIRECTOR
Credential: DDS
Phone: 562-933-3141