Healthcare Provider Details

I. General information

NPI: 1295145662
Provider Name (Legal Business Name): MY DENTIST AND ME PEDIATRIC DENTISTRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/06/2014
Last Update Date: 05/06/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 CANYON CREST DR #309
RIVERSIDE CA
92507-6301
US

IV. Provider business mailing address

5225 CANYON CREST DR #309
RIVERSIDE CA
92507-6301
US

V. Phone/Fax

Practice location:
  • Phone: 712-574-3307
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number56036
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number61151
License Number StateCA

VIII. Authorized Official

Name: CHRISTINE MIN
Title or Position: PARTNER
Credential: DDS
Phone: 712-574-3307