Healthcare Provider Details

I. General information

NPI: 1093372351
Provider Name (Legal Business Name): ESCONDIDO PEDIATRIC DENTISTRY, A DENTAL OFFICE OF DR. CHRISTIAN M FORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2019
Last Update Date: 05/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 E PENNSYLVANIA AVE STE I
ESCONDIDO CA
92025-3432
US

IV. Provider business mailing address

925 E PENNSYLVANIA AVE STE I
ESCONDIDO CA
92025-3432
US

V. Phone/Fax

Practice location:
  • Phone: 760-743-7176
  • Fax:
Mailing address:
  • Phone: 760-743-7176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. CHRISTIAN M FORTNEY CICCARELLA
Title or Position: PRESIDENT
Credential: DDS
Phone: 760-317-9598