Basic Information
Provider Information
NPI: 1952660326
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: FOTADAR
FirstName: MAXINE
MiddleName: MARY
NamePrefix:  
NameSuffix:  
Credential: D.D.S.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 737 W CHILDS AVE
Address2:  
City: MERCED
State: CA
PostalCode: 953416805
CountryCode: US
TelephoneNumber: 2093831848
FaxNumber: 2093831296
Practice Location
Address1: 9235 E BROADWAY ST
Address2:  
City: PLANADA
State: CA
PostalCode: 953658088
CountryCode: US
TelephoneNumber: 2093820253
FaxNumber: 2093822110
Other Information
ProviderEnumerationDate: 05/04/2012
LastUpdateDate: 10/01/2014
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
1223G0001X62818CAY Dental ProvidersDentistGeneral Practice

No ID Information.


Home