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General NPI Number Information
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NPI Number | 1770708299
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Entity Type | Organization
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Legal Business Name | CHILDREN'S DENTAL INITIATIVE
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Dates
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Enumeration Date | 04/17/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2085 HAMILTON AVE STE. 150
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City | SAN JOSE
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State | CA
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Zip | 95125-6117
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Country | US
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Telephone | 408-961-9869
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Fax |
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Provider Business Mailing Address
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Address Line | 2085 HAMILTON AVE STE. 150
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City | SAN JOSE
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State | CA
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Zip | 95125-6117
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Country | US
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Telephone | 408-961-9869
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Fax |
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Authorized Official
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Title or Position | CHIEF FINANCIAL OFFICER
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Name | MR. IRA HOLTZMAN
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Credential |
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Telephone | 408-961-9869
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | G91493-02
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License Number State | CA
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