Healthcare Provider Details

I. General information

NPI: 1144636291
Provider Name (Legal Business Name): GOLETA NEIGHBORHOOD DENTAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2014
Last Update Date: 03/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

164 KINMAN AVE
GOLETA CA
93117-3481
US

IV. Provider business mailing address

915 N MILPAS ST 2ND FLOOR
SANTA BARBARA CA
93103-2331
US

V. Phone/Fax

Practice location:
  • Phone: 805-617-7900
  • Fax: 805-617-7899
Mailing address:
  • Phone: 805-617-7850
  • Fax: 805-963-8880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. CHARLES CAMILLO FENZI
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: M.D.
Phone: 805-617-7850