Provider Demographics
NPI:1952581282
Name:DEMETRIO STA ANA JR DDS INC
Entity Type:Organization
Organization Name:DEMETRIO STA ANA JR DDS INC
Other - Org Name:SHAW FAMILY DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEMETRIO
Authorized Official - Middle Name:TAGULINAO
Authorized Official - Last Name:STA. ANA
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:559-277-0111
Mailing Address - Street 1:3616 W. SHAW AVENUE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711
Mailing Address - Country:US
Mailing Address - Phone:559-277-0111
Mailing Address - Fax:
Practice Address - Street 1:3616 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3231
Practice Address - Country:US
Practice Address - Phone:559-277-0111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEMETRIO STA ANA JR DDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-11-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43250122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA43250OtherDENTAL LICENSE
CA43250OtherDENTAL LICENSE