1235291568 NPI number — HEALTHY SMILES MOBILE DENTAL FOUNDATION

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 1235291568 NPI number — HEALTHY SMILES MOBILE DENTAL FOUNDATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HEALTHY SMILES MOBILE DENTAL FOUNDATION
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:
1235291568
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/17/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

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

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2045 N DOWER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRESNO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93723-9503
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
559-229-6437
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KODAMA
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
559-229-6437

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  D38861 , 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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