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General NPI Number Information
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NPI Number | 1093372351
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Entity Type | Organization
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Legal Business Name | ESCONDIDO PEDIATRIC DENTISTRY, A DENTAL OFFICE OF DR. CHRISTIAN M FORT
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Dates
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Enumeration Date | 05/22/2019
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Last Update Date | 05/22/2019
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Provider Practice Location Address
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Address Line | 925 E PENNSYLVANIA AVE STE I
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City | ESCONDIDO
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State | CA
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Zip | 92025-3432
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Country | US
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Telephone | 760-743-7176
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Fax |
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Provider Business Mailing Address
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Address Line | 925 E PENNSYLVANIA AVE STE I
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City | ESCONDIDO
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State | CA
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Zip | 92025-3432
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Country | US
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Telephone | 760-743-7176
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. CHRISTIAN M FORTNEY CICCARELLA
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Credential | DDS
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Telephone | 760-317-9598
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number |
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License Number State |
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