Provider Demographics
NPI:1760517213
Name:CHILDREN'S DENTAL FOUNDATION
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL FOUNDATION
Other - Org Name:CHILDREN'S DENTAL HEALTH CLINIC
Other - Org Type:Doing Business As
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 1:455 E COLUMBIA ST
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1620
Mailing Address - Country:US
Mailing Address - Phone:562-933-3141
Mailing Address - Fax:562-933-2049
Practice Address - Street 1:455 E COLUMBIA ST
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1620
Practice Address - Country:US
Practice Address - Phone:562-933-3141
Practice Address - Fax:562-933-2049
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1223E0200X, 1223G0001X, 1223P0221X, 1223P0300X, 1223S0112X, 1223X0400X, 124Q00000X, 126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0221XDental ProvidersDentistPediatric DentistryGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty
Not Answered124Q00000XDental ProvidersDental HygienistGroup - Multi-Specialty
Not Answered126800000XDental ProvidersDental AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG90360-01OtherDENTI-CAL PROVIDER NUMBER