Provider Demographics
NPI:1497181184
Name:JUAN ALZATE DENTAL CORPORATION
Entity Type:Organization
Organization Name:JUAN ALZATE DENTAL CORPORATION
Other - Org Name:JUAN JOSE ALZATE, DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:ALZATE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-554-9323
Mailing Address - Street 1:5670 N FRESNO ST STE 107
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8330
Mailing Address - Country:US
Mailing Address - Phone:559-554-9323
Mailing Address - Fax:559-554-9758
Practice Address - Street 1:5670 N FRESNO ST STE 107
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8330
Practice Address - Country:US
Practice Address - Phone:559-554-9323
Practice Address - Fax:559-554-9758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-25
Last Update Date:2018-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========Medicaid
CA=========OtherDENTI-CAL