Provider Demographics
NPI:1427177815
Name:FOOTHILL DENTAL CARE
Entity type:Organization
Organization Name:FOOTHILL DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:EZZATI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:650-949-4734
Mailing Address - Street 1:881 FREMONT AVE STE B1
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94024-5637
Mailing Address - Country:US
Mailing Address - Phone:650-949-4734
Mailing Address - Fax:
Practice Address - Street 1:881 FREMONT AVE STE B1
Practice Address - Street 2:
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-5637
Practice Address - Country:US
Practice Address - Phone:650-949-4734
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37544122300000X
CA35491122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty