Healthcare Provider Details

I. General information

NPI: 1225274400
Provider Name (Legal Business Name): CHRISTINA M VIDAL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHRISTINA M VIDAL R.D.A

II. Dates (important events)

Enumeration Date: 12/18/2008
Last Update Date: 01/12/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W SHAW 110
CLOVIS CA
93612
US

IV. Provider business mailing address

5140 E KING CANYON
FRESNO CA
93727
US

V. Phone/Fax

Practice location:
  • Phone: 559-325-6161
  • Fax:
Mailing address:
  • Phone: 559-248-6663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number62632
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: