Provider Demographics
NPI: | 1508052382 |
---|---|
Name: | BIRCH DENTAL GROUP |
Entity Type: | Organization |
Organization Name: | BIRCH DENTAL GROUP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | OWNER |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | CLARK |
Authorized Official - Middle Name: | L |
Authorized Official - Last Name: | FONG, DDS |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | DDS |
Authorized Official - Phone: | 650-366-0552 |
Mailing Address - Street 1: | 155 BIRCH ST |
Mailing Address - Street 2: | SUITE 5 |
Mailing Address - City: | REDWOOD CITY |
Mailing Address - State: | CA |
Mailing Address - Zip Code: | 94062-1340 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 650-366-0552 |
Mailing Address - Fax: | 650-366-0701 |
Practice Address - Street 1: | 155 BIRCH ST |
Practice Address - Street 2: | SUITE 5 |
Practice Address - City: | REDWOOD CITY |
Practice Address - State: | CA |
Practice Address - Zip Code: | 94062-1340 |
Practice Address - Country: | US |
Practice Address - Phone: | 650-366-0552 |
Practice Address - Fax: | 650-366-0701 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2007-09-14 |
Last Update Date: | 2010-03-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CA | 40351 | 1223G0001X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Single Specialty |