Healthcare Provider Details

I. General information

NPI: 1659773208
Provider Name (Legal Business Name): FRESNO ENDODONTIC GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2014
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1332 W. HERNDON STE. 103
FRESNO CA
93711
US

IV. Provider business mailing address

1332 W. HERNDON STE. 103
FRESNO CA
93711
US

V. Phone/Fax

Practice location:
  • Phone: 559-437-7120
  • Fax: 559-437-7131
Mailing address:
  • Phone: 559-437-7120
  • Fax: 559-437-7131

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State

VIII. Authorized Official

Name: AARON RUSSELL JENSEN
Title or Position: OWNER
Credential:
Phone: 559-437-7120