Provider Demographics
NPI:1255502522
Name:NANCY DERHAM DENTAL CORPORATION
Entity Type:Organization
Organization Name:NANCY DERHAM DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:
Authorized Official - Last Name:DERHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-892-4721
Mailing Address - Street 1:1805 NOVATO BLVD
Mailing Address - Street 2:#6
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-2934
Mailing Address - Country:US
Mailing Address - Phone:415-892-4721
Mailing Address - Fax:415-892-5921
Practice Address - Street 1:1805 NOVATO BLVD
Practice Address - Street 2:#6
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-2934
Practice Address - Country:US
Practice Address - Phone:415-892-4721
Practice Address - Fax:415-892-5921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA389141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty