Healthcare Provider Details

I. General information

NPI: 1306034293
Provider Name (Legal Business Name): DENNIS J. WIDMAN, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2007
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4860 CHERRY AVE SUITE B
SAN JOSE CA
95118-3716
US

IV. Provider business mailing address

4860 CHERRY AVE SUITE B
SAN JOSE CA
95118-3716
US

V. Phone/Fax

Practice location:
  • Phone: 408-265-4480
  • Fax: 408-997-2946
Mailing address:
  • Phone: 408-265-4480
  • Fax: 408-997-2946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number18666
License Number StateCA

VIII. Authorized Official

Name: DR. DENNIS JORDAN WIDMAN
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 408-265-4480