Healthcare Provider Details

I. General information

NPI: 1346763158
Provider Name (Legal Business Name): POWELL PEDIATRIC DENTISTRY INGRAM PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 07/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7761 N INGRAM AVE SUITE 101
FRESNO CA
93711
US

IV. Provider business mailing address

7761 N INGRAM AVE SUITE #101
FRESNO CA
93711
US

V. Phone/Fax

Practice location:
  • Phone: 559-431-9701
  • Fax:
Mailing address:
  • Phone: 559-431-9701
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number State

VIII. Authorized Official

Name: MR. BRENT DAVID POWELL
Title or Position: MANAGING PARTNER
Credential: DMD
Phone: 559-321-1833