Provider Demographics
NPI:1326174319
Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Entity Type:Organization
Organization Name:ST. JOSEPH HEALTH NORTHERN CALIFORNIA, LLC
Other - Org Name:ST. JOSEPH HEALTH MOBILE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSISTANT SECRETARY FOR ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:425-525-5392
Mailing Address - Street 1:751 LOMBARDI CT
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-6793
Mailing Address - Country:US
Mailing Address - Phone:707-547-2237
Mailing Address - Fax:707-547-2230
Practice Address - Street 1:751 LOMBARDI CT
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407
Practice Address - Country:US
Practice Address - Phone:707-547-2237
Practice Address - Fax:707-547-2230
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST JOSEPH HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-26
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA110000498261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG9048301OtherMEDICAL PROVIDER NUMBER