Healthcare Provider Details

I. General information

NPI: 1003102443
Provider Name (Legal Business Name): CALIFORNIA KIDDS PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/23/2011
Last Update Date: 06/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7525 N. CEDAR AVE #105
FRESNO CA
93720
US

IV. Provider business mailing address

7525 N. CEDAR AVE #105
FRESNO CA
93720
US

V. Phone/Fax

Practice location:
  • Phone: 559-439-6600
  • Fax: 559-439-5400
Mailing address:
  • Phone: 559-439-6600
  • Fax: 559-439-5400

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number60083
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number59512
License Number StateCA

VIII. Authorized Official

Name: JEFFREY B EVANS
Title or Position: OWNER/PARTNER
Credential: DDS
Phone: 559-439-6600