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General NPI Number Information
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NPI Number | 1992314421
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Entity Type | Organization
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Legal Business Name | CENTER FOR IMPLANT DENTISTRY PRESTIGE DENTAL GROUP
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Dates
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Enumeration Date | 07/30/2020
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Last Update Date | 07/30/2020
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Provider Practice Location Address
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Address Line | 3381 WALNUT AVE
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City | FREMONT
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State | CA
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Zip | 94538-2217
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Country | US
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Telephone | 510-574-0496
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Fax | 510-574-0499
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Provider Business Mailing Address
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Address Line | 3381 WALNUT AVE
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City | FREMONT
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State | CA
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Zip | 94538-2217
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Country | US
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Telephone | 510-574-0496
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Fax | 510-574-0499
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Authorized Official
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Title or Position | BILLING MANGER
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Name | MANUEL FUENTES
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Credential |
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Telephone | 310-870-9652
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223S0112X
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Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
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License Number |
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License Number State |
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