Provider Demographics
NPI:1326354754
Name:TRINITY RIVER DENTAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:TRINITY RIVER DENTAL PROFESSIONAL CORPORATION
Other - Org Name:NORTHERN CALIFORNIA DENTAL SLEEP THERAPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PREDDIS
Authorized Official - Middle Name:LEROY
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-517-9905
Mailing Address - Street 1:3620 N CREST CT
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-1019
Mailing Address - Country:US
Mailing Address - Phone:916-517-9905
Mailing Address - Fax:
Practice Address - Street 1:1619 N WATERFRONT PKWY
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67206-6602
Practice Address - Country:US
Practice Address - Phone:916-517-9905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-23
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA545001223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFM340AMedicare UPIN
CA6448090001Medicare NSC