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General NPI Number Information
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NPI Number | 1861979544
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Entity Type | Organization
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Legal Business Name | POWELL PEDIATRIC DENTISTRY CHESTNUT PARTNERSHIP
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Dates
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Enumeration Date | 07/25/2018
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Last Update Date | 07/25/2018
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Provider Practice Location Address
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Address Line | 7005 N. CHESTNUT AVE STE 101
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City | FRESNO
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State | CA
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Zip | 93720
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Country | US
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Telephone | 559-299-5949
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Fax | 559-299-7880
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Provider Business Mailing Address
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Address Line | 7005 N. CHESTNUT AVE STE. 101
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City | FRESNO
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State | CA
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Zip | 93720
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Country | US
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Telephone | 559-299-5949
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Fax | 559-299-7880
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. BRENT D POWELL
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Credential | DMD
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Telephone | 559-299-3949
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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 | 101165
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 1223P0221X
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Taxonomy Name | Pediatric Dentistry
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License Number | 56148
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License Number State | CA
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