Provider Demographics
NPI:1316547524
Name:INGERSOLL PARK MARINA GP DENTAL CORPORATION
Entity Type:Organization
Organization Name:INGERSOLL PARK MARINA GP DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREK
Authorized Official - Middle Name:JEFFREY
Authorized Official - Last Name:INGERSOLL
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:919-656-3004
Mailing Address - Street 1:3300 N TRIUMPH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5046
Mailing Address - Country:US
Mailing Address - Phone:801-494-4949
Mailing Address - Fax:
Practice Address - Street 1:2301 PARK MARINA DR STE 27
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2158
Practice Address - Country:US
Practice Address - Phone:801-494-4949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental