1295139590 NPI number — TOLOSA CHILDRENS DENTAL CENTER

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295139590 NPI number — TOLOSA CHILDRENS DENTAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TOLOSA CHILDRENS DENTAL CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295139590
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
717 WALNUT DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PASO ROBLES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93446-2315
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-238-5334
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4251 S HIGUERA ST STE 401
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-7714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-238-2216
Provider Business Practice Location Address Fax Number:
805-238-6470
Provider Enumeration Date:
10/15/2014

Additional Information

Authorized Official

Authorized Official Last Name:
RUSSELL
Authorized Official First Name:
SUZANNE
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINIC DIRECTOR
Authorized Official Telephone Number:
805-238-2216

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  D50253 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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