Provider Demographics
NPI:1043309727
Name:SANTA ROSA DENTAL
Entity Type:Organization
Organization Name:SANTA ROSA DENTAL
Other - Org Name:DINU A GRAY, DDS/MYRNA MENJIVAR GRAY,DDS/EUGENE FIELD,DDS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:MENJIVAR GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-299-9566
Mailing Address - Street 1:188 STANFORD AVE
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-3546
Mailing Address - Country:US
Mailing Address - Phone:415-389-9566
Mailing Address - Fax:415-389-9563
Practice Address - Street 1:2360 MENDOCINO AVE
Practice Address - Street 2:SUITE A 6
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-3153
Practice Address - Country:US
Practice Address - Phone:707-568-1436
Practice Address - Fax:707-568-1483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA304331223G0001X
CA304611223G0001X
CA300681223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty