Provider Demographics
NPI:1427021757
Name:ACREE-ISENHOWER DENTAL COPORATION
Entity Type:Organization
Organization Name:ACREE-ISENHOWER DENTAL COPORATION
Other - Org Name:FIRST SMILES CHILDREN'S DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ACREE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-529-0674
Mailing Address - Street 1:1801 TULLY ROAD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350
Mailing Address - Country:US
Mailing Address - Phone:209-343-3500
Mailing Address - Fax:209-527-1971
Practice Address - Street 1:1801 TULLY ROAD
Practice Address - Street 2:SUITE B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350
Practice Address - Country:US
Practice Address - Phone:209-343-3500
Practice Address - Fax:209-527-1971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-08
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA488701223G0001X
CA488801223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20789OtherDENTAL LICENSE
CA20789OtherDENTAL LICENSE