Healthcare Provider Details

I. General information

NPI: 1235406331
Provider Name (Legal Business Name): MADERA KIDS DENTAL WORLD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 11/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 W CLEVELAND AVE STE D
MADERA CA
93637-8723
US

IV. Provider business mailing address

2295 W CLEVELAND AVE STE D
MADERA CA
93637-8723
US

V. Phone/Fax

Practice location:
  • Phone: 559-273-4696
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number55210
License Number StateCA

VIII. Authorized Official

Name: MRS. NADEZHDA SARGSYAN
Title or Position: PRESIDENT
Credential: DDS
Phone: 559-273-4696