Healthcare Provider Details

I. General information

NPI: 1609273101
Provider Name (Legal Business Name): CHILDREN'S DENTISTRY AND ORTHODONTICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 08/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 N FRESNO ST STE 103
FRESNO CA
93710-5270
US

IV. Provider business mailing address

6245 N FRESNO ST STE 103
FRESNO CA
93710-5270
US

V. Phone/Fax

Practice location:
  • Phone: 559-554-9999
  • Fax:
Mailing address:
  • Phone: 559-554-9999
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateCA

VIII. Authorized Official

Name: STEVE OHARA
Title or Position: PRESIDENT
Credential: DDS, MSD
Phone: 559-554-9999