Provider Demographics
NPI:1346763158
Name:POWELL PEDIATRIC DENTISTRY INGRAM PARTNERSHIP
Entity Type:Organization
Organization Name:POWELL PEDIATRIC DENTISTRY INGRAM PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:POWELL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:559-321-1833
Mailing Address - Street 1:7761 N INGRAM AVE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711
Mailing Address - Country:US
Mailing Address - Phone:559-431-9701
Mailing Address - Fax:
Practice Address - Street 1:7761 N INGRAM AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711
Practice Address - Country:US
Practice Address - Phone:559-431-9701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty