Healthcare Provider Details

I. General information

NPI: 1952528671
Provider Name (Legal Business Name): JASON SORENSEN D.D.S. A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 12/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 W HERNDON AVE
FRESNO CA
93711-0552
US

IV. Provider business mailing address

1480 W HERNDON AVE
FRESNO CA
93711-0552
US

V. Phone/Fax

Practice location:
  • Phone: 559-447-0544
  • Fax: 559-431-1827
Mailing address:
  • Phone: 559-447-0544
  • Fax: 559-431-1827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number46690
License Number StateCA

VIII. Authorized Official

Name: DR. JASON SORENSEN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 559-447-0544