MEDICARE: HEALTHY SMILES MOBILE DENTAL FOUNDATION

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D38861	CA

General Provider Information

NPI Number	:	1235291568
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEALTHY SMILES MOBILE DENTAL FOUNDATION

Provider Business Mailing Address
First Line	:	2045 N DOWER AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93723-9503
Country	:	US
Telephone Number	:	559-229-6437
Fax Number	:

Provider Business Practice Location Address
First Line	:	2045 N DOWER AVE
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93723-9503
Country	:	US
Telephone Number	:	559-229-6437
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	MRS. SUSAN KODAMA
Credential	:
Telephone Number	:	559-229-6437

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	08/17/2020

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