Provider Demographics
NPI:1124419122
Name:I DENTAL FAMILY DENTISTRY JUAN C HUAMAN DDS,CORP
Entity Type:Organization
Organization Name:I DENTAL FAMILY DENTISTRY JUAN C HUAMAN DDS,CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING DR
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:HUAMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-673-7700
Mailing Address - Street 1:620 W YOSEMITE AVE
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93637-4523
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:620 W YOSEMITE AVE
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93637-4523
Practice Address - Country:US
Practice Address - Phone:559-673-7700
Practice Address - Fax:559-673-7702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-11
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59160122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA122300000XOtherGENERAL DENTIST