Provider Demographics
NPI:1487065454
Name:HENRY D. FAJARDO, D.M.D., INC.
Entity type:Organization
Organization Name:HENRY D. FAJARDO, D.M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:DOLOSO
Authorized Official - Last Name:FAJARDO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:559-224-5988
Mailing Address - Street 1:2100 E. CLINTON AVE.
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93703-2134
Mailing Address - Country:US
Mailing Address - Phone:559-224-5988
Mailing Address - Fax:559-224-5933
Practice Address - Street 1:2100 E CLINTON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-2134
Practice Address - Country:US
Practice Address - Phone:559-224-5988
Practice Address - Fax:559-224-5933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-13
Last Update Date:2014-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45107122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty