Provider Demographics
NPI:1609418987
Name:FARGO DENTAL CORPORATION
Entity Type:Organization
Organization Name:FARGO DENTAL CORPORATION
Other - Org Name:BJB DENTAL GROUP A PROFESSIONAL DENTAL CORPORATION
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CO-OWNER/DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:BASSAM
Authorized Official - Middle Name:WISAM
Authorized Official - Last Name:FARGO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:951-329-7904
Mailing Address - Street 1:8275 SIERRA AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92335-3557
Mailing Address - Country:US
Mailing Address - Phone:909-823-7567
Mailing Address - Fax:909-823-8341
Practice Address - Street 1:8275 SIERRA AVE STE 102
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92335-3557
Practice Address - Country:US
Practice Address - Phone:909-823-7567
Practice Address - Fax:909-823-8341
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-08
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental