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General NPI Number Information
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NPI Number | 1295139590
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Entity Type | Organization
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Legal Business Name | TOLOSA CHILDRENS DENTAL CENTER
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Dates
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Enumeration Date | 10/15/2014
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Last Update Date | 07/02/2019
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Provider Practice Location Address
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Address Line | 4251 S HIGUERA ST STE 401
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City | SAN LUIS OBISPO
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State | CA
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Zip | 93401-7714
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Country | US
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Telephone | 805-238-2216
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Fax | 805-238-6470
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Provider Business Mailing Address
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Address Line | 717 WALNUT DR
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City | PASO ROBLES
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State | CA
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Zip | 93446-2315
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Country | US
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Telephone | 805-238-5334
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Fax |
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Authorized Official
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Title or Position | CLINIC DIRECTOR
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Name | SUZANNE RUSSELL
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Credential |
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Telephone | 805-238-2216
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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 | D50253
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License Number State | CA
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