Provider Demographics
NPI:1093372351
Name:ESCONDIDO PEDIATRIC DENTISTRY, A DENTAL OFFICE OF DR. CHRISTIAN M FORT
Entity Type:Organization
Organization Name:ESCONDIDO PEDIATRIC DENTISTRY, A DENTAL OFFICE OF DR. CHRISTIAN M FORT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:FORTNEY CICCARELLA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:760-317-9598
Mailing Address - Street 1:925 E PENNSYLVANIA AVE STE I
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-3432
Mailing Address - Country:US
Mailing Address - Phone:760-743-7176
Mailing Address - Fax:
Practice Address - Street 1:925 E PENNSYLVANIA AVE STE I
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-3432
Practice Address - Country:US
Practice Address - Phone:760-743-7176
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty