Provider Demographics
NPI:1619694734
Name:PALM BLUFFS DENTAL GROUP, INC. PRACTICE OF DR. PRIETO
Entity Type:Organization
Organization Name:PALM BLUFFS DENTAL GROUP, INC. PRACTICE OF DR. PRIETO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DDS/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:PRIETO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-906-0209
Mailing Address - Street 1:1900 SHAW AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-4209
Mailing Address - Country:US
Mailing Address - Phone:559-906-0209
Mailing Address - Fax:
Practice Address - Street 1:7766 N PALM AVE STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-5734
Practice Address - Country:US
Practice Address - Phone:559-906-0209
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-20
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223D0001XDental ProvidersDentistDental Public HealthGroup - Single Specialty