1174038517 NPI number — DALLA PEDIATRIC DENTAL INC

Table of content: (NPI 1174038517)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174038517 NPI number — DALLA PEDIATRIC DENTAL INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DALLA PEDIATRIC DENTAL INC
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:
Provider Other Organization Name Type Code:
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:
1174038517
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/07/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3108 E PINTAIL WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELK GROVE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95757-8206
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
917 TRANCAS ST STE B
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NAPA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94558-2903
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
707-226-5559
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/07/2017

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DALLA
Authorized Official First Name:
DEVAN
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
646-427-6519

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X , with the licence number:  63130 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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