Provider Demographics
NPI:1194212134
Name:TOOTH SPA DENTISTRY
Entity Type:Organization
Organization Name:TOOTH SPA DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER, DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:M
Authorized Official - Last Name:HERMO
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-209-3708
Mailing Address - Street 1:831 STERLING PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-7323
Mailing Address - Country:US
Mailing Address - Phone:916-209-3708
Mailing Address - Fax:888-858-1377
Practice Address - Street 1:831 STERLING PKWY STE 130
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-7323
Practice Address - Country:US
Practice Address - Phone:916-209-3708
Practice Address - Fax:888-858-1377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58867261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental