Provider Demographics
NPI:1790900215
Name:CHILDREN'S DENTAL INITIATIVE
Entity Type:Organization
Organization Name:CHILDREN'S DENTAL INITIATIVE
Other - Org Name:THE HEALTH TRUST
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HOLTZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-961-9869
Mailing Address - Street 1:2085 HAMILTON AVE
Mailing Address - Street 2:STE. 150
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95125-6117
Mailing Address - Country:US
Mailing Address - Phone:408-961-9869
Mailing Address - Fax:
Practice Address - Street 1:645 WOOL CREEK DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-2617
Practice Address - Country:US
Practice Address - Phone:408-961-9869
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG91493-01261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91493-01Medicaid