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General NPI Number Information
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NPI Number | 1235291568
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Entity Type | Organization
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Legal Business Name | HEALTHY SMILES MOBILE DENTAL FOUNDATION
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Dates
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Enumeration Date | 12/14/2006
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Last Update Date | 08/17/2020
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Provider Practice Location Address
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Address Line | 2045 N DOWER AVE
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City | FRESNO
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State | CA
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Zip | 93723-9503
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Country | US
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Telephone | 559-229-6437
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Fax |
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Provider Business Mailing Address
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Address Line | 2045 N DOWER AVE
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City | FRESNO
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State | CA
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Zip | 93723-9503
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Country | US
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Telephone | 559-229-6437
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Fax |
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Authorized Official
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Title or Position | CHIEF EXECUTIVE OFFICER
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Name | MRS. SUSAN KODAMA
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Credential |
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Telephone | 559-229-6437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | D38861
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License Number State | CA
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