Healthcare Provider Details

I. General information

NPI: 1124140751
Provider Name (Legal Business Name): THOUSAND OAKS CHILDRENS DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 02/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 LONG CT SUITE 202
THOUSAND OAKS CA
91360
US

IV. Provider business mailing address

61 LONG CT SUITE 202
THOUSAND OAKS CA
91360
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-3797
  • Fax: 805-371-1121
Mailing address:
  • Phone: 805-497-3797
  • Fax: 805-371-1121

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number036029
License Number StateCA

VIII. Authorized Official

Name: MR. AHSAN S RAZA
Title or Position: OWNER/PARTNER
Credential: D.D.S.
Phone: 805-497-3797