Provider Demographics
NPI:1619179629
Name:CHICO PERIODONTAL ASSOCIATES
Entity Type:Organization
Organization Name:CHICO PERIODONTAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELEANOR
Authorized Official - Middle Name:T
Authorized Official - Last Name:WARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:530-898-1234
Mailing Address - Street 1:30 DECLARATION DR
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95973-4911
Mailing Address - Country:US
Mailing Address - Phone:530-898-1234
Mailing Address - Fax:530-898-0725
Practice Address - Street 1:30 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-4911
Practice Address - Country:US
Practice Address - Phone:530-898-1234
Practice Address - Fax:530-898-0725
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA358821223P0300X
CA419591223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty