Provider Demographics
NPI:1760254239
Name:TRAHAN PEDIATRIC DENTAL GROUP
Entity Type:Organization
Organization Name:TRAHAN PEDIATRIC DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:TRAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:805-456-2866
Mailing Address - Street 1:1111 E OCEAN AVE STE 4B
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-2500
Mailing Address - Country:US
Mailing Address - Phone:805-456-2866
Mailing Address - Fax:805-456-0350
Practice Address - Street 1:1111 E OCEAN AVE STE 4B
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2500
Practice Address - Country:US
Practice Address - Phone:805-456-2866
Practice Address - Fax:805-456-0350
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-26
Last Update Date:2023-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0221XDental ProvidersDentistPediatric DentistryGroup - Single Specialty