1295139590 NPI number — TOLOSA CHILDRENS DENTAL CENTER

Table of content: (NPI 1295139590)

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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