=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487800215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TURLOCK ORAL AND MAXILLOFACIAL SUGERY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/12/2008
-----------------------------------------------------
Last Update Date | 08/12/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1810 N OLIVE AVE STE 8
-----------------------------------------------------
City | TURLOCK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95382-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-667-5050
-----------------------------------------------------
Fax | 209-667-7559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1810 N OLIVE AVE STE 8
-----------------------------------------------------
City | TURLOCK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95382-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-667-5050
-----------------------------------------------------
Fax | 209-667-7559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. VICTOR T PAK
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 209-667-5050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 53549
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------