1235377623 NPI number — DIAMOND SPRINGS DENTAL

Table of content: (NPI 1235377623)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235377623 NPI number — DIAMOND SPRINGS DENTAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DIAMOND SPRINGS DENTAL
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:
6
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:
1235377623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/04/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 500
Provider Second Line Business Mailing Address:
STE. 102
Provider Business Mailing Address City Name:
DIAMOND SPRINGS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95619-0500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
530-344-0290
Provider Business Mailing Address Fax Number:
530-344-0291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
540 MAIN STREET
Provider Second Line Business Practice Location Address:
STE. 102 POST OFFICE BOX 500
Provider Business Practice Location Address City Name:
DIAMOND SPRINGS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95619-0500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
530-344-0290
Provider Business Practice Location Address Fax Number:
530-344-0291
Provider Enumeration Date:
01/23/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GOODIS
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DENTIST
Authorized Official Telephone Number:
530-344-0290

Provider Taxonomy Codes

  • Taxonomy code: 122300000X , with the licence number:  D43010 , 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)

  • Identifier: 130082 . This is a "UMITED CONCORDIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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