Provider Demographics
NPI:1467417378
Name:LERIAN DENTAL CORPORATION
Entity Type:Organization
Organization Name:LERIAN DENTAL CORPORATION
Other - Org Name:GENTLE DENTAL HILLSDALE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:FAITH
Authorized Official - Middle Name:RAMIENTOS
Authorized Official - Last Name:TABUJARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-476-4728
Mailing Address - Street 1:555 W BENJAMIN HOLT DR
Mailing Address - Street 2:BLDG B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3839
Mailing Address - Country:US
Mailing Address - Phone:209-476-4700
Mailing Address - Fax:209-478-8758
Practice Address - Street 1:360 HILLSDALE MALL
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94403-3425
Practice Address - Country:US
Practice Address - Phone:650-341-8008
Practice Address - Fax:650-341-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138471223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty