Healthcare Provider Details

I. General information

NPI: 1619694734
Provider Name (Legal Business Name): PALM BLUFFS DENTAL GROUP, INC. PRACTICE OF DR. PRIETO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2022
Last Update Date: 10/31/2022
Certification Date: 10/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7766 N PALM AVE STE 104
FRESNO CA
93711-5734
US

IV. Provider business mailing address

1900 SHAW AVE STE 101
CLOVIS CA
93611-4209
US

V. Phone/Fax

Practice location:
  • Phone: 559-906-0209
  • Fax:
Mailing address:
  • Phone: 559-906-0209
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: DR. JORDAN DAVID PRIETO
Title or Position: DDS/OWNER
Credential:
Phone: 559-906-0209