Provider Demographics
NPI:1467653105
Name:FRED HANOSH D.D.S. PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:FRED HANOSH D.D.S. PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:NORMAN
Authorized Official - Last Name:HANOSH
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-872-1020
Mailing Address - Street 1:6161 CLARK RD STE 8
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-4164
Mailing Address - Country:US
Mailing Address - Phone:530-872-1020
Mailing Address - Fax:530-877-7555
Practice Address - Street 1:6161 CLARK RD STE 8
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-4164
Practice Address - Country:US
Practice Address - Phone:530-872-1020
Practice Address - Fax:530-877-7555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247921223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT08627Medicare UPIN
CADS0247920Medicare ID - Type Unspecified