=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487789889
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JAIRO H MOLTA DDS.INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/23/2007
-----------------------------------------------------
Last Update Date | 12/07/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 371 E BULLARD AVE STE 118
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-5217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-440-0150
-----------------------------------------------------
Fax | 559-435-4370
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 371 E BULLARD AVE STE 118
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93710-5217
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-440-0150
-----------------------------------------------------
Fax | 559-435-4370
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JAIRO H MOLTA
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 559-440-0150
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 53629
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------