Provider Demographics
NPI:1285183194
Name:FENNY VIRGIN, DDS, INC.
Entity Type:Organization
Organization Name:FENNY VIRGIN, DDS, INC.
Other - Org Name:CHINO SPECTRUM DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:VIRGIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-627-9996
Mailing Address - Street 1:4036 GRAND AVE
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHINO
Mailing Address - State:CA
Mailing Address - Zip Code:91710-5487
Mailing Address - Country:US
Mailing Address - Phone:909-627-9996
Mailing Address - Fax:909-517-1035
Practice Address - Street 1:4036 GRAND AVE
Practice Address - Street 2:SUITE D
Practice Address - City:CHINO
Practice Address - State:CA
Practice Address - Zip Code:91710-5487
Practice Address - Country:US
Practice Address - Phone:909-627-9996
Practice Address - Fax:909-517-1035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-04
Last Update Date:2016-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental