Basic Information
| Provider Information | |||||||||
| NPI: | 1104838010 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGIO | ||||||||
| FirstName: | PETER | ||||||||
| MiddleName: | JOHN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.D.S | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GEORGIO | ||||||||
| OtherFirstName: | PETER | ||||||||
| OtherMiddleName: | JOHN | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.D.S | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2263 W BIRCH AVE | ||||||||
| Address2: | |||||||||
| City: | FRESNO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 937110442 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5594318515 | ||||||||
| FaxNumber: | 5592272880 | ||||||||
| Practice Location | |||||||||
| Address1: | 16835 ALKALI DR | ||||||||
| Address2: | SUITE M | ||||||||
| City: | LEMOORE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 932459463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5599240460 | ||||||||
| FaxNumber: | 5599242197 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | CA26640 | CA | Y | Dental Providers | Dentist | Dental Public Health |
ID Information
| ID | Type | State | Issuer | Description | 26640 | 05 | CA | MEDICAID |