Healthcare Provider Details

I. General information

NPI: 1801186556
Provider Name (Legal Business Name): WEST COAST DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 04/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 SHAW AVE STE 103
CLOVIS CA
93612-3985
US

IV. Provider business mailing address

1330 SHAW AVE STE 103
CLOVIS CA
93612-3985
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number75261
License Number StateCA

VIII. Authorized Official

Name: MICHAEL SHAUN CREDILLE
Title or Position: REGISTERED DENTAL ASSISTANT
Credential: RDA
Phone: 559-325-6161