Provider Demographics
NPI:1790153328
Name:WISDOM4DENTAL
Entity Type:Organization
Organization Name:WISDOM4DENTAL
Other - Org Name:VALLADARES COLASSE DENTAL PARTNERSHIP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILIPPE
Authorized Official - Middle Name:ANDRE
Authorized Official - Last Name:COLASSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-300-0813
Mailing Address - Street 1:1791 MARLOW RD
Mailing Address - Street 2:SUITE 1-D
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4151
Mailing Address - Country:US
Mailing Address - Phone:702-300-0813
Mailing Address - Fax:
Practice Address - Street 1:1791 MARLOW RD
Practice Address - Street 2:SUITE 1-D
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4151
Practice Address - Country:US
Practice Address - Phone:702-300-0813
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-14
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA610111223G0001X
CA610661223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty