MEDICARE: MEREDITH C MOCK DDS INC

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	122300000X	Dentist	21170	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	B2117001	OTHER		DELTA DENTALS STATE GOVER

General Provider Information

NPI Number	:	1780666974
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MEREDITH C MOCK DDS INC

Provider Business Mailing Address
First Line	:	3727 N 1ST ST
Second Line	:	SUITE 102
City	:	FRESNO
State	:	CA
Zip	:	93726-5628
Country	:	US
Telephone Number	:	559-229-3541
Fax Number	:	559-229-2421

Provider Business Practice Location Address
First Line	:	3727 N 1ST ST
Second Line	:	SUITE 102
City	:	FRESNO
State	:	CA
Zip	:	93726-5628
Country	:	US
Telephone Number	:	559-229-3541
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT DENTIST
Name	:	MEREDITH COLE MOCK
Credential	:	DDS
Telephone Number	:	559-229-3541

Provider Enumeration Date	:	11/15/2005
Last Update Date	:	08/22/2020

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