Provider Demographics
NPI:1295139590
Name:TOLOSA CHILDRENS DENTAL CENTER
Entity type:Organization
Organization Name:TOLOSA CHILDRENS DENTAL CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CLINIC DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SUZANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-238-2216
Mailing Address - Street 1:717 WALNUT DR
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-2315
Mailing Address - Country:US
Mailing Address - Phone:805-238-5334
Mailing Address - Fax:
Practice Address - Street 1:4251 S HIGUERA ST STE 401
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7714
Practice Address - Country:US
Practice Address - Phone:805-238-2216
Practice Address - Fax:805-238-6470
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TOLOSA CHILDREN'S DENTAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-15
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD502531223P0221X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty