Provider Demographics
NPI:1679981898
Name:MOLTA, JAIRO HUMBERTO (DDS)
Entity Type:Individual
Prefix:
First Name:JAIRO
Middle Name:HUMBERTO
Last Name:MOLTA
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:371 E BULLARD AVE
Mailing Address - Street 2:SUITE 118
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-5217
Mailing Address - Country:US
Mailing Address - Phone:559-440-0150
Mailing Address - Fax:559-435-4370
Practice Address - Street 1:371 E BULLARD AVE
Practice Address - Street 2:SUITE 118
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5217
Practice Address - Country:US
Practice Address - Phone:559-440-0150
Practice Address - Fax:559-435-4370
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-31
Last Update Date:2014-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53629122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA523435OtherDENTI-CAL