Provider Demographics
NPI:1164488730
Name:LERIAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:LERIAN DENTAL CORPORATION
Other - Org Name:GENTLE DENTAL PETALUMA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PC HOLDER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:LERIAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:707-765-9262
Mailing Address - Street 1:555 W BENJAMIN HOLT DR
Mailing Address - Street 2:BLDG. B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3839
Mailing Address - Country:US
Mailing Address - Phone:209-476-4700
Mailing Address - Fax:209-478-8758
Practice Address - Street 1:229 N MCDOWELL BLVD
Practice Address - Street 2:
Practice Address - City:PETALUMA
Practice Address - State:CA
Practice Address - Zip Code:94954-2306
Practice Address - Country:US
Practice Address - Phone:707-765-9262
Practice Address - Fax:707-765-9261
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty