Provider Demographics
NPI:1245628270
Name:EDITH MORA DMD, INC.
Entity type:Organization
Organization Name:EDITH MORA DMD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:EDITH
Authorized Official - Middle Name:IVONNE
Authorized Official - Last Name:MORA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:209-462-2452
Mailing Address - Street 1:3133 W MARCH LN STE 1080
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2360
Mailing Address - Country:US
Mailing Address - Phone:209-951-4304
Mailing Address - Fax:
Practice Address - Street 1:3133 W MARCH LN STE 1080
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-2360
Practice Address - Country:US
Practice Address - Phone:209-951-4304
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-29
Last Update Date:2015-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA534701223G0001X
CA582141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty