Provider Demographics
NPI:1881110328
Name:WISDOM TEETH AWAY INCORPORATED DENTAL PRACTICE OF JUAN JOSE ALZATE D.D
Entity type:Organization
Organization Name:WISDOM TEETH AWAY INCORPORATED DENTAL PRACTICE OF JUAN JOSE ALZATE D.D
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:ALZATE
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-447-5781
Mailing Address - Street 1:5640 N FRESNO STREET
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93710-8330
Mailing Address - Country:US
Mailing Address - Phone:559-447-5781
Mailing Address - Fax:559-272-0370
Practice Address - Street 1:5640 N FRESNO STREET
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-8330
Practice Address - Country:US
Practice Address - Phone:559-447-5781
Practice Address - Fax:559-272-0370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-16
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50558122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty