Provider Demographics
NPI:1114175817
Name:HILDEBRAND, DERRY L JR (DDS)
Entity Type:Individual
Prefix:
First Name:DERRY
Middle Name:L
Last Name:HILDEBRAND
Suffix:JR
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:296 W SIERRA AVENUE
Mailing Address - Street 2:STE 1
Mailing Address - City:PORTOLA
Mailing Address - State:CA
Mailing Address - Zip Code:96122-8627
Mailing Address - Country:US
Mailing Address - Phone:530-832-0200
Mailing Address - Fax:530-832-0900
Practice Address - Street 1:296 W SIERRA AVE.
Practice Address - Street 2:STE 1
Practice Address - City:PORTOLA
Practice Address - State:CA
Practice Address - Zip Code:96122-8627
Practice Address - Country:US
Practice Address - Phone:530-832-0200
Practice Address - Fax:530-832-0900
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19626122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist