1205922705 NPI number — CENTRAL COAST PEDIATRIC DENTAL GROUP

Table of content: (NPI 1205922705)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205922705 NPI number — CENTRAL COAST PEDIATRIC DENTAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL COAST PEDIATRIC DENTAL GROUP
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:
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:
1205922705
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/29/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
631 E ALVIN DRIVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
SALINAS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
831-442-8878
Provider Business Mailing Address Fax Number:
831-443-4611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
633 E ALVIN DR STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SALINAS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93906-3000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
831-443-1177
Provider Business Practice Location Address Fax Number:
831-443-0705
Provider Enumeration Date:
10/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LIZAOLA
Authorized Official First Name:
ANNA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
ADMINISTRATIVE ASSISTANT
Authorized Official Telephone Number:
831-442-8878

Provider Taxonomy Codes

  • Taxonomy code: 1223P0221X , with the licence number:  37400 , 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)

  • Identifier: G9087502 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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