Provider Demographics
NPI:1598259459
Name:DENTURE & IMPLANT CENTERS OF AMERICA
Entity Type:Organization
Organization Name:DENTURE & IMPLANT CENTERS OF AMERICA
Other - Org Name:DENTURE & IMPLANT CENTER OF FRESNO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER - DENTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-277-3001
Mailing Address - Street 1:6495 N. PALM AVE ST #105
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93704
Mailing Address - Country:US
Mailing Address - Phone:559-277-3001
Mailing Address - Fax:559-277-3031
Practice Address - Street 1:6495 N. PALM AVE ST #105
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93704
Practice Address - Country:US
Practice Address - Phone:559-277-3001
Practice Address - Fax:559-277-3031
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-14
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty