Provider Demographics
NPI:1306034293
Name:DENNIS J. WIDMAN, DDS, INC.
Entity Type:Organization
Organization Name:DENNIS J. WIDMAN, DDS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:JORDAN
Authorized Official - Last Name:WIDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:408-265-4480
Mailing Address - Street 1:4860 CHERRY AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-3716
Mailing Address - Country:US
Mailing Address - Phone:408-265-4480
Mailing Address - Fax:408-997-2946
Practice Address - Street 1:4860 CHERRY AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-3716
Practice Address - Country:US
Practice Address - Phone:408-265-4480
Practice Address - Fax:408-997-2946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-05
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18666261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD18666OtherMEDICAL, DENTICAL