Provider Demographics
NPI:1033214283
Name:PARTNERSHIP FOR THE CHILDREN OF SAN LUIS OBISPO CO
Entity Type:Organization
Organization Name:PARTNERSHIP FOR THE CHILDREN OF SAN LUIS OBISPO CO
Other - Org Name:TOLOSA CHILDRENS DENTAL CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOLLISTER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-543-6963
Mailing Address - Street 1:717 WALNUT DRIVE
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-2315
Mailing Address - Country:US
Mailing Address - Phone:805-238-5334
Mailing Address - Fax:805-238-6470
Practice Address - Street 1:717 WALNUT DRIVE
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-2315
Practice Address - Country:US
Practice Address - Phone:805-238-5334
Practice Address - Fax:805-238-6470
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4192751GMedicaid