Provider Demographics
NPI:1225274400
Name:VIDAL, CHRISTINA M
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:M
Last Name:VIDAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:M
Other - Last Name:VIDAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDA
Mailing Address - Street 1:5140 E KING CANYON
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727
Mailing Address - Country:US
Mailing Address - Phone:559-248-6663
Mailing Address - Fax:
Practice Address - Street 1:200 W SHAW
Practice Address - Street 2:110
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93612
Practice Address - Country:US
Practice Address - Phone:559-325-6161
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-18
Last Update Date:2009-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA62632126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant