Provider Demographics
NPI:1326468752
Name:GREATER MODESTO DENTAL IMPLANT &ORAL SURGERY CENTER
Entity Type:Organization
Organization Name:GREATER MODESTO DENTAL IMPLANT &ORAL SURGERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VICTORIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRUNO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-527-5050
Mailing Address - Street 1:201 E ORANGEBURG AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5355
Mailing Address - Country:US
Mailing Address - Phone:209-527-5050
Mailing Address - Fax:209-527-0659
Practice Address - Street 1:201 E ORANGEBURG AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-5355
Practice Address - Country:US
Practice Address - Phone:209-527-5050
Practice Address - Fax:209-527-0659
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-24
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA324471223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
U05250Medicare UPIN
U11212Medicare UPIN