Provider Demographics
NPI:1811435092
Name:FAIR OAKS ORTHODONTICS
Entity type:Organization
Organization Name:FAIR OAKS ORTHODONTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:626-795-5978
Mailing Address - Street 1:1318 FAIR OAKS AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-3808
Mailing Address - Country:US
Mailing Address - Phone:626-795-5978
Mailing Address - Fax:626-796-1173
Practice Address - Street 1:1318 FAIR OAKS AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-3808
Practice Address - Country:US
Practice Address - Phone:626-795-5978
Practice Address - Fax:626-796-1173
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA557261223X0400X
CA580431223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty