Healthcare Provider Details

I. General information

NPI: 1043143696
Provider Name (Legal Business Name): LODI KIDS DENTIST A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2026
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

740 W KETTLEMAN LN
LODI CA
95240-6051
US

IV. Provider business mailing address

9707 BLANSFIELD WAY
ELK GROVE CA
95757-4021
US

V. Phone/Fax

Practice location:
  • Phone: 209-808-5439
  • Fax:
Mailing address:
  • Phone: 916-849-3174
  • 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 State

VIII. Authorized Official

Name: AHMED SALEM
Title or Position: CEO
Credential: DDS
Phone: 916-849-3174