Healthcare Provider Details

I. General information

NPI: 1558503060
Provider Name (Legal Business Name): MUNOZ, FORBES, SOUZA, LEE, KANO & CONLEY A DENTAL CORP.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

529 E CENTER ST
MANTECA CA
95336-4719
US

IV. Provider business mailing address

909 W ROSEBURG AVE STE A
MODESTO CA
95350-5062
US

V. Phone/Fax

Practice location:
  • Phone: 209-526-3815
  • Fax: 209-579-9521
Mailing address:
  • Phone: 209-526-3815
  • Fax: 209-579-9521

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number43926
License Number StateCA

VIII. Authorized Official

Name: MR. JAMES A CONLEY
Title or Position: SECRETARY
Credential: DDS
Phone: 209-526-3815