Healthcare Provider Details

I. General information

NPI: 1952660326
Provider Name (Legal Business Name): MAXINE MARY FOTADAR D.D.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2012
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9235 E BROADWAY ST
PLANADA CA
95365-8088
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 209-382-0253
  • Fax: 209-382-2110
Mailing address:
  • Phone: 209-383-1848
  • Fax: 209-383-1296

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number62818
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: