Provider Demographics
NPI:1134660913
Name:TRITON DENTAL, LLC
Entity Type:Organization
Organization Name:TRITON DENTAL, LLC
Other - Org Name:YOSEMITE DENTAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:WIEG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:909-269-1277
Mailing Address - Street 1:PO BOX 219
Mailing Address - Street 2:
Mailing Address - City:MARIPOSA
Mailing Address - State:CA
Mailing Address - Zip Code:95338-0219
Mailing Address - Country:US
Mailing Address - Phone:559-683-4662
Mailing Address - Fax:
Practice Address - Street 1:49722 ROAD 426
Practice Address - Street 2:SUITE 104
Practice Address - City:OAKHURST
Practice Address - State:CA
Practice Address - Zip Code:93644-9047
Practice Address - Country:US
Practice Address - Phone:559-683-4662
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-14
Last Update Date:2017-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA60387122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty