Provider Demographics
NPI:1417176058
Name:FOOTHILL DENTAL PRACTICE
Entity Type:Organization
Organization Name:FOOTHILL DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALLEN
Authorized Official - Middle Name:STEVENSON
Authorized Official - Last Name:LATHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-781-2611
Mailing Address - Street 1:5070 FOOTHILLS BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-6500
Mailing Address - Country:US
Mailing Address - Phone:916-781-2611
Mailing Address - Fax:916-781-2760
Practice Address - Street 1:5070 FOOTHILLS BLVD STE 2
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-6500
Practice Address - Country:US
Practice Address - Phone:916-781-2611
Practice Address - Fax:916-781-2760
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty