Provider Demographics
NPI:1710161880
Name:THE CHILDREN'S DENTAL FOUNDATION
Entity Type:Organization
Organization Name:THE CHILDREN'S DENTAL FOUNDATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:562-933-3141
Mailing Address - Street 1:200 FALLS CANYON ROAD
Mailing Address - Street 2:
Mailing Address - City:AVALON
Mailing Address - State:CA
Mailing Address - Zip Code:90704
Mailing Address - Country:US
Mailing Address - Phone:310-510-8287
Mailing Address - Fax:
Practice Address - Street 1:200 FALLS CANYON ROAD
Practice Address - Street 2:
Practice Address - City:AVALON
Practice Address - State:CA
Practice Address - Zip Code:90704
Practice Address - Country:US
Practice Address - Phone:310-510-8287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHILDREN'S DENTAL HEALTH CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-12-24
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122300000X
1223P0221X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
No1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
No126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90360-03OtherDENTI-CAL STATE PROGRAM