Provider Demographics
NPI:1619126398
Name:HACIENDA DENTAL, INC
Entity Type:Organization
Organization Name:HACIENDA DENTAL, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:JR
Authorized Official - Credentials:DDS
Authorized Official - Phone:925-734-0104
Mailing Address - Street 1:5674 STONERIDGE DR
Mailing Address - Street 2:SUITE 111
Mailing Address - City:PLEASANTON
Mailing Address - State:CA
Mailing Address - Zip Code:94588-8500
Mailing Address - Country:US
Mailing Address - Phone:925-734-0104
Mailing Address - Fax:924-734-0489
Practice Address - Street 1:5674 STONERIDGE DR
Practice Address - Street 2:SUITE 111
Practice Address - City:PLEASANTON
Practice Address - State:CA
Practice Address - Zip Code:94588-8500
Practice Address - Country:US
Practice Address - Phone:925-734-0104
Practice Address - Fax:924-734-0489
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-17
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24840122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty