Provider Demographics
NPI:1588672695
Name:GENERAL DENTISTRY FOR CHILDREN: DENTAL GROUP OF KLEINSASSER DENTAL COR
Entity Type:Organization
Organization Name:GENERAL DENTISTRY FOR CHILDREN: DENTAL GROUP OF KLEINSASSER DENTAL COR
Other - Org Name:SAME
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICK
Authorized Official - Middle Name:J
Authorized Official - Last Name:KLEINSASSER
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-922-3530
Mailing Address - Street 1:1430 E MAIN ST STE 203
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4832
Mailing Address - Country:US
Mailing Address - Phone:805-922-3530
Mailing Address - Fax:805-928-4776
Practice Address - Street 1:1430 E MAIN ST STE 203
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-4832
Practice Address - Country:US
Practice Address - Phone:805-922-3530
Practice Address - Fax:805-928-4776
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA293301223G0001X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA810275OtherUNITED CONCORDIA PROVIDER