Healthcare Provider Details

I. General information

NPI: 1750392007
Provider Name (Legal Business Name): KILMER AND COSTANZO A GENERAL PARTNERSHIP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6307 N FRESNO ST STE 101
FRESNO CA
93710
US

IV. Provider business mailing address

6307 N FRESNO ST STE 101
FRESNO CA
93710
US

V. Phone/Fax

Practice location:
  • Phone: 559-435-5033
  • Fax: 559-435-5048
Mailing address:
  • Phone: 559-435-5033
  • Fax: 559-435-5048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number50234
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number234622
License Number StateCA

VIII. Authorized Official

Name: MRS. CAROL J RODRIGUEZ
Title or Position: OFFICE MANAGER
Credential:
Phone: 559-435-5033