1104264985 NPI number — REEVES, D.D.S. AND LAVALLEY, D.D.S., A DENTAL CORPORATION

Table of content: (NPI 1104264985)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104264985 NPI number — REEVES, D.D.S. AND LAVALLEY, D.D.S., A DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
REEVES, D.D.S. AND LAVALLEY, D.D.S., A DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
KIDS CARE DENTAL & ORTHODONTICS - STOCKTON
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104264985
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/09/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3100 ZINFANDEL DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO CORDOVA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95670-6391
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-570-1500
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3485 BROOKSIDE RD
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
STOCKTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95219-1757
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
209-957-4386
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/13/2013

Additional Information

Authorized Official

Authorized Official Last Name:
BOYES
Authorized Official First Name:
DEREK
Authorized Official Middle Name:
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
916-570-1500

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223P0221X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 1223S0112X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223X0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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