Provider Demographics
NPI:1598993198
Name:PEDIATRIC DENTAL INITIATIVE OF THE NORTH COAST, INC.
Entity Type:Organization
Organization Name:PEDIATRIC DENTAL INITIATIVE OF THE NORTH COAST, INC.
Other - Org Name:PDI SURGERY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR/DIRECTOR OF NURSING
Authorized Official - Prefix:MS
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:BELLE
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:707-838-6560
Mailing Address - Street 1:1380 19TH HOLE DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7713
Mailing Address - Country:US
Mailing Address - Phone:707-838-6560
Mailing Address - Fax:707-838-8464
Practice Address - Street 1:1380 19TH HOLE DR
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-7713
Practice Address - Country:US
Practice Address - Phone:707-838-6560
Practice Address - Fax:707-838-8464
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-23
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000658261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical