Healthcare Provider Details

I. General information

NPI: 1780900480
Provider Name (Legal Business Name): PACIFIC HOLISTIC DENTAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2010
Last Update Date: 09/26/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 W TEFFT ST
NIPOMO CA
93444-8946
US

IV. Provider business mailing address

530 W TEFFT ST
NIPOMO CA
93444-8946
US

V. Phone/Fax

Practice location:
  • Phone: 805-929-6814
  • Fax: 805-929-2047
Mailing address:
  • Phone: 805-929-6814
  • Fax: 805-929-2047

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number57466
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number57466
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number57466
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number57466
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number57466
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License Number57466
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number57466
License Number StateCA
# 8
Primary TaxonomyN
Taxonomy Code208VP0000X
TaxonomyPain Medicine Physician
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code204E00000X
TaxonomyOral & Maxillofacial Surgery (D.M.D.)
License Number57466
License Number StateCA
# 11
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number57466
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DR. EDWARD SHAPIRO
Title or Position: OWNER/ OPERATOR
Credential: D.D.S
Phone: 805-929-6814