Provider Demographics
NPI:1033960471
Name:PEBBLE BEACH DENTAL OF GRASS VALLEY
Entity Type:Organization
Organization Name:PEBBLE BEACH DENTAL OF GRASS VALLEY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ATHERLY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:916-751-0995
Mailing Address - Street 1:300 SIERRA COLLEGE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945-5083
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 SIERRA COLLEGE DR STE 110
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-5083
Practice Address - Country:US
Practice Address - Phone:530-272-6312
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-01
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty