Provider Demographics
NPI:1053643783
Name:VISALIA CHILDREN'S DENTAL SURGERY CENTER INC
Entity Type:Organization
Organization Name:VISALIA CHILDREN'S DENTAL SURGERY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:SHUBERT
Authorized Official - Last Name:RICKS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-625-9300
Mailing Address - Street 1:PO BOX 7599
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93290-7599
Mailing Address - Country:US
Mailing Address - Phone:559-625-9300
Mailing Address - Fax:559-625-9330
Practice Address - Street 1:136 ASPEN COURT
Practice Address - Street 2:SUITE A
Practice Address - City:VISALIA
Practice Address - State:CA
Practice Address - Zip Code:93291
Practice Address - Country:US
Practice Address - Phone:559-625-9300
Practice Address - Fax:559-625-9330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-05
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23135261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical