Provider Demographics
NPI:1316188436
Name:KOLL CENTER DENTAL GROUP
Entity Type:Organization
Organization Name:KOLL CENTER DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRYSTYNE
Authorized Official - Middle Name:
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-484-2828
Mailing Address - Street 1:6654 KOLL CENTER PKWY STE 350
Mailing Address - Street 2:
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94566-3125
Mailing Address - Country:US
Mailing Address - Phone:925-484-2828
Mailing Address - Fax:925-484-4504
Practice Address - Street 1:6654 KOLL CENTER PKWY STE 350
Practice Address - Street 2:
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94566-3125
Practice Address - Country:US
Practice Address - Phone:925-484-2828
Practice Address - Fax:925-484-4504
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-19
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA472581223G0001X
CA492071223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty