Provider Demographics
NPI:1093422040
Name:TOOTH FAIRIES OF CALIFORNIA
Entity Type:Organization
Organization Name:TOOTH FAIRIES OF CALIFORNIA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:MIRA
Authorized Official - Middle Name:
Authorized Official - Last Name:YANG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-502-7252
Mailing Address - Street 1:10373 GILLIAM DR
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-3512
Mailing Address - Country:US
Mailing Address - Phone:916-502-7252
Mailing Address - Fax:
Practice Address - Street 1:7915 LAGUNA BLVD STE 105
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7945
Practice Address - Country:US
Practice Address - Phone:916-502-7252
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-10-31
Last Update Date:2022-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare