Provider Demographics
NPI:1164622882
Name:FREMONT HEALTH CENTER DENTAL GROUP
Entity Type:Organization
Organization Name:FREMONT HEALTH CENTER DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:O.M
Authorized Official - Prefix:MISS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:PIPPENGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-463-2345
Mailing Address - Street 1:2043 E FREMONT ST STE 1
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-5000
Mailing Address - Country:US
Mailing Address - Phone:209-463-2345
Mailing Address - Fax:209-463-1432
Practice Address - Street 1:2043 E FREMONT ST STE 1
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-5000
Practice Address - Country:US
Practice Address - Phone:209-463-2345
Practice Address - Fax:209-463-1432
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREMONT HEALTH CENTER DENTAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-20
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD37743122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G89962-01OtherDENTICAL