Provider Demographics
NPI:1750506036
Name:SLADE DMD CORPORATION
Entity Type:Organization
Organization Name:SLADE DMD CORPORATION
Other - Org Name:PEACH TREE DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:TROY
Authorized Official - Middle Name:KENDALL
Authorized Official - Last Name:SLADE
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:805-544-7804
Mailing Address - Street 1:862 MEINECKE AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405
Mailing Address - Country:US
Mailing Address - Phone:805-544-7804
Mailing Address - Fax:805-544-6020
Practice Address - Street 1:862 MEINECKE AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405
Practice Address - Country:US
Practice Address - Phone:805-544-7804
Practice Address - Fax:805-544-6020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA588001223G0001X
CA628981223G0001X
CA446051223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty