Healthcare Provider Details

I. General information

NPI: 1790034700
Provider Name (Legal Business Name): S M KIWAN, DDS, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2012
Last Update Date: 09/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4820 N. 1ST STREET SUITE 105
FRESNO CA
93726-0522
US

IV. Provider business mailing address

4820 N. 1ST STREET SUITE 105
FRESNO CA
93726-0522
US

V. Phone/Fax

Practice location:
  • Phone: 559-224-3110
  • Fax: 559-227-7752
Mailing address:
  • Phone: 559-224-3110
  • Fax: 559-227-7752

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number50411
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number50411
License Number StateCA

VIII. Authorized Official

Name: DR. SALEEM M KIWAN
Title or Position: PROVIDER/OWNER/PRESIDENT
Credential: DDS
Phone: 559-224-3110