Healthcare Provider Details

I. General information

NPI: 1073669503
Provider Name (Legal Business Name): HENRY CAMILO CISNEROS JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2007
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NORTH BRIDGE STREET
VISALIA CA
93291-5014
US

IV. Provider business mailing address

305 EAST CENTER AVE.
VISALIA CA
93291-6331
US

V. Phone/Fax

Practice location:
  • Phone: 559-734-1939
  • Fax: 559-734-4384
Mailing address:
  • Phone: 559-727-4700
  • Fax: 559-737-4782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number29239
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: