Provider Demographics
NPI:1235291568
Name:HEALTHY SMILES MOBILE DENTAL FOUNDATION
Entity Type:Organization
Organization Name:HEALTHY SMILES MOBILE DENTAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KODAMA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-229-6437
Mailing Address - Street 1:2045 N DOWER AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93723-9503
Mailing Address - Country:US
Mailing Address - Phone:559-229-6437
Mailing Address - Fax:
Practice Address - Street 1:2045 N DOWER AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93723-9503
Practice Address - Country:US
Practice Address - Phone:559-229-6437
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD388611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9807401OtherHEALTHY FAMILIES PROGRAM
CAG9807401OtherHEALTHY FAMILIES PROGRAM