Healthcare Provider Details

I. General information

NPI: 1689138703
Provider Name (Legal Business Name): GREEN VALLEY ORAL SURGERY AND DENTAL IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2019
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5140 BUSINESS CENTER DR STE 120
FAIRFIELD CA
94534-1794
US

IV. Provider business mailing address

5140 BUSINESS CENTER DR STE 120
FAIRFIELD CA
94534-1794
US

V. Phone/Fax

Practice location:
  • Phone: 707-800-3114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. YAHYA RADWAN
Title or Position: PARTNER
Credential:
Phone: 408-221-9333