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General NPI Number Information
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NPI Number | 1811435092
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Entity Type | Organization
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Legal Business Name | FAIR OAKS ORTHODONTICS
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Dates
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Enumeration Date | 02/07/2017
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Last Update Date | 02/07/2017
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Provider Practice Location Address
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Address Line | 1318 FAIR OAKS AVE SUITE A
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City | SOUTH PASADENA
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State | CA
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Zip | 91030-3808
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Country | US
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Telephone | 626-795-5978
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Fax | 626-796-1173
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Provider Business Mailing Address
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Address Line | 1318 FAIR OAKS AVE SUITE A
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City | SOUTH PASADENA
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State | CA
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Zip | 91030-3808
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Country | US
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Telephone | 626-795-5978
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Fax | 626-796-1173
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Authorized Official
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Title or Position | INSURANCE COORDINATOR
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Name | SHARON BRADLEY
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Credential |
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Telephone | 626-795-5978
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 55726
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number | 58043
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License Number State | CA
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