# CENTER FOR IMPLANT DENTISTRY PRESTIGE DENTAL GROUP

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1992314421
- **Authorized official:** MANUEL FUENTES (BILLING MANGER)
- **Authorized official phone:** (310) 870-9652

## Contact information

- **Practice address:** 3381 WALNUT AVE, FREMONT, CA 94538-2217
- **Practice address phone:** (510) 574-0496
- **Practice address fax:** (510) 574-0499
- **Mailing address:** 3381 WALNUT AVE, FREMONT, CA 94538-2217
- **Mailing address phone:** (510) 574-0496
- **Mailing address fax:** (510) 574-0499

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | NULL | Yes |
| 1223S0112X | Oral and Maxillofacial Surgery (Dentist) | — | — | Yes |

## Other

- **Enumeration date:** 07/30/2020
- **Last updated:** 07/30/2020