Healthcare Provider Details

I. General information

NPI: 1104838010
Provider Name (Legal Business Name): PETER JOHN GEORGIO D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PETER JOHN GEORGIO D.D.S

II. Dates (important events)

Enumeration Date: 08/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16835 ALKALI DR SUITE M
LEMOORE CA
93245-9463
US

IV. Provider business mailing address

2263 W BIRCH AVE
FRESNO CA
93711-0442
US

V. Phone/Fax

Practice location:
  • Phone: 559-924-0460
  • Fax: 559-924-2197
Mailing address:
  • Phone: 559-431-8515
  • Fax: 559-227-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberCA26640
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: