Healthcare Provider Details

I. General information

NPI: 1760517213
Provider Name (Legal Business Name): CHILDREN'S DENTAL FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 E COLUMBIA ST
LONG BEACH CA
90806-1620
US

IV. Provider business mailing address

455 E COLUMBIA ST
LONG BEACH CA
90806-1620
US

V. Phone/Fax

Practice location:
  • Phone: 562-933-3141
  • Fax: 562-933-2049
Mailing address:
  • Phone: 562-933-3141
  • Fax: 562-933-2049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number StateCA

VIII. Authorized Official

Name: DR. JOHN BLAKE
Title or Position: DENTAL DIRECTOR
Credential: D.D.S.
Phone: 562-933-3141