Provider Demographics
NPI:1376933622
Name:CENTER FOR ORAL HEALTH
Entity Type:Organization
Organization Name:CENTER FOR ORAL HEALTH
Other - Org Name:CENTER FOR ORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:CONRADO
Authorized Official - Middle Name:
Authorized Official - Last Name:BARZAGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-469-8300
Mailing Address - Street 1:309 EAST SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-1854
Mailing Address - Country:US
Mailing Address - Phone:909-469-8300
Mailing Address - Fax:510-380-6637
Practice Address - Street 1:9309 N FLORIDA AVE STE 111
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-7237
Practice Address - Country:US
Practice Address - Phone:813-473-8200
Practice Address - Fax:813-315-7104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-26
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X
122300000X, 1223P0221X, 1223S0112X
FL1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
No122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL021277800Medicaid