Healthcare Provider Details

I. General information

NPI: 1053643783
Provider Name (Legal Business Name): VISALIA CHILDREN'S DENTAL SURGERY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/05/2010
Last Update Date: 01/27/2025
Certification Date: 01/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 ASPEN COURT SUITE A
VISALIA CA
93291
US

IV. Provider business mailing address

9709 LAKESIDE BLVD STE 350
SPRING TX
77381-1213
US

V. Phone/Fax

Practice location:
  • Phone: 559-625-9300
  • Fax: 559-625-9330
Mailing address:
  • Phone: 713-489-2198
  • Fax: 713-489-2978

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number23135
License Number StateCA

VIII. Authorized Official

Name: MR. DEVIN LARSEN
Title or Position: CEO
Credential:
Phone: 208-340-1840