1639174279 NPI number — A PROFESSIONAL DENTAL CORP.

Table of content: (NPI 1639174279)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639174279 NPI number — A PROFESSIONAL DENTAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
A PROFESSIONAL DENTAL CORP.
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:
1639174279
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3505 LONE TREE WAY
Provider Second Line Business Mailing Address:
STE 7
Provider Business Mailing Address City Name:
ANTIOCH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94509-6067
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
925-756-7884
Provider Business Mailing Address Fax Number:
925-756-7894

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3505 LONE TREE WAY
Provider Second Line Business Practice Location Address:
STE 7
Provider Business Practice Location Address City Name:
ANTIOCH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94509-6067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
925-756-7884
Provider Business Practice Location Address Fax Number:
925-756-7894
Provider Enumeration Date:
06/20/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BUTTI
Authorized Official First Name:
KELLY
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
925-756-7884

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X , with the licence number:  40072 , 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)





Copyright © 2007-2025 www.npivalidator.com