Healthcare Provider Details

I. General information

NPI: 1023693470
Provider Name (Legal Business Name): MORA FAMILY DENTAL GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 PENNSYLVANIA AVE
FAIRFIELD CA
94533-3507
US

IV. Provider business mailing address

1402 PENNSYLVANIA AVE
FAIRFIELD CA
94533-3507
US

V. Phone/Fax

Practice location:
  • Phone: 707-425-6216
  • Fax: 707-425-6241
Mailing address:
  • Phone: 707-425-6216
  • Fax: 707-425-6241

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LAUREL SANTOS
Title or Position: OFFICE MANAGER, SHAREHOLDER
Credential: D.D.S.
Phone: 707-425-6216