Provider Demographics
NPI:1821019407
Name:DISICK DENTAL CORPORATION
Entity Type:Organization
Organization Name:DISICK DENTAL CORPORATION
Other - Org Name:EVAN S. DISICK, D.D.S.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVAN
Authorized Official - Middle Name:SCHAFFER
Authorized Official - Last Name:DISICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-381-4321
Mailing Address - Street 1:591 REDWOOD HWY
Mailing Address - Street 2:BUILDING 2000, SUITE 2110
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-6001
Mailing Address - Country:US
Mailing Address - Phone:415-381-4321
Mailing Address - Fax:415-381-4056
Practice Address - Street 1:591 REDWOOD HWY
Practice Address - Street 2:BUILDING 2000, SUITE 2110
Practice Address - City:MILL VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94941-6001
Practice Address - Country:US
Practice Address - Phone:415-381-4321
Practice Address - Fax:415-381-4056
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty