| Fruitvale Dental Group | |
|
1624 Franklin St Suite 1206 Oakland CA 94612-2824 | |
| (510) 452-5555 | |
| Not Available |
| Full Name | Fruitvale Dental Group |
|---|---|
| Speciality | Dentist |
| Location | 1624 Franklin St, Oakland, California |
| Authorized Official Name and Position | Richard H. Mogensen (PRESIDENT) |
| Authorized Official Contact | 5104525555 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
| Fruitvale Dental Group 1624 Franklin St Suite 1206 Oakland CA 94612-2824 Ph: (510) 452-5555 | Fruitvale Dental Group 1624 Franklin St Suite 1206 Oakland CA 94612-2824 Ph: (510) 452-5555 |
| NPI Number | 1750595567 |
|---|---|
| Provider Enumeration Date | 05/10/2007 |
| Last Update Date | 08/22/2020 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1750595567 | NPI | - | NPPES |
| G92157-01 | Medicaid | CA |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 122300000X | Dentist | CA 21733 (California) | Primary |
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