Healthcare Provider Details

I. General information

NPI: 1922132216
Provider Name (Legal Business Name): RAJI HADDAD D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 W. SHAW AVE
FRESNO CA
93704
US

IV. Provider business mailing address

310 W SHAW AVE
FRESNO CA
93704-2646
US

V. Phone/Fax

Practice location:
  • Phone: 559-229-8200
  • Fax: 559-229-2971
Mailing address:
  • Phone: 559-229-8200
  • Fax: 559-229-2971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number39001
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: