Provider Demographics
NPI:1558503060
Name:MUNOZ, FORBES, SOUZA, LEE, KANO & CONLEY A DENTAL CORP.
Entity type:Organization
Organization Name:MUNOZ, FORBES, SOUZA, LEE, KANO & CONLEY A DENTAL CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:CONLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-526-3815
Mailing Address - Street 1:909 W ROSEBURG AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-5062
Mailing Address - Country:US
Mailing Address - Phone:209-526-3815
Mailing Address - Fax:209-579-9521
Practice Address - Street 1:529 E CENTER ST
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-4719
Practice Address - Country:US
Practice Address - Phone:209-526-3815
Practice Address - Fax:209-579-9521
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA43926122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953OtherFNP