Healthcare Provider Details

I. General information

NPI: 1750481735
Provider Name (Legal Business Name): FRESNO ORAL MAXILLOFACIAL SURGERY AND DENTAL IMPLANT CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1903 E FIR AVE STE 101
FRESNO CA
93720-3862
US

IV. Provider business mailing address

1903 E FIR AVE STE 101
FRESNO CA
93720-3862
US

V. Phone/Fax

Practice location:
  • Phone: 559-226-2722
  • Fax: 559-226-6989
Mailing address:
  • Phone: 559-226-2722
  • Fax: 559-226-6989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MR. RYAN SMITH
Title or Position: DIRECTOR OF OPERATIONS
Credential:
Phone: 559-326-5932