Provider Demographics
NPI:1750481735
Name:FRESNO ORAL MAXILLOFACIAL SURGERY AND DENTAL IMPLANT CENTER
Entity Type:Organization
Organization Name:FRESNO ORAL MAXILLOFACIAL SURGERY AND DENTAL IMPLANT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:559-326-5932
Mailing Address - Street 1:1903 E FIR AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-3862
Mailing Address - Country:US
Mailing Address - Phone:559-226-2722
Mailing Address - Fax:559-226-6989
Practice Address - Street 1:1903 E FIR AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3862
Practice Address - Country:US
Practice Address - Phone:559-226-2722
Practice Address - Fax:559-226-6989
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-22
Last Update Date:2021-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty