Provider Demographics
NPI:1679797930
Name:PEDIATRIC DENTISTRY OF LOS ALTOS
Entity Type:Organization
Organization Name:PEDIATRIC DENTISTRY OF LOS ALTOS
Other - Org Name:PEDIATRIC DENTISTRY OF LOS ALTOS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-948-6884
Mailing Address - Street 1:731 ALTOS OAKS DR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5402
Mailing Address - Country:US
Mailing Address - Phone:650-948-6884
Mailing Address - Fax:650-948-7244
Practice Address - Street 1:731 ALTOS OAKS DR
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5402
Practice Address - Country:US
Practice Address - Phone:650-948-6884
Practice Address - Fax:650-948-7244
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA303951223P0221X
CA381011223P0221X
CA217181223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR=========OtherGROUP DENTAL PRACTICE