Provider Demographics
NPI:1194991190
Name:BLOSSOM HILL DENTAL CLINIC
Entity type:Organization
Organization Name:BLOSSOM HILL DENTAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:YURI
Authorized Official - Middle Name:
Authorized Official - Last Name:UNDORF
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-752-5605
Mailing Address - Street 1:5460 DELLWOOD WAY STE A
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-2965
Mailing Address - Country:US
Mailing Address - Phone:408-266-1117
Mailing Address - Fax:
Practice Address - Street 1:5460 DELLWOOD WAY STE A
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-2965
Practice Address - Country:US
Practice Address - Phone:408-266-1117
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RICHMOND DENTAL CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40751122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9111501OtherDENTI CAL NUMBER ISSUED FOR OFFICE #1