Healthcare Provider Details

I. General information

NPI: 1639443575
Provider Name (Legal Business Name): OTTO R. ALONZO, D.D.S., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2012
Last Update Date: 02/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 SHAW AVE SUITE B2
CLOVIS CA
93612-3841
US

IV. Provider business mailing address

145 SHAW AVE SUITE B2
CLOVIS CA
93612-3841
US

V. Phone/Fax

Practice location:
  • Phone: 559-325-2175
  • Fax: 559-325-2227
Mailing address:
  • Phone: 559-325-2175
  • Fax: 559-325-2227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number50719
License Number StateCA

VIII. Authorized Official

Name: DR. OTTO RAUL ALONZO
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 559-776-1829