Provider Demographics
NPI:1942375068
Name:YULY VILDERMAN DDS A DENTAL CORPORATION
Entity Type:Organization
Organization Name:YULY VILDERMAN DDS A DENTAL CORPORATION
Other - Org Name:HARBOR DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:YULY
Authorized Official - Middle Name:
Authorized Official - Last Name:VILDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-372-8525
Mailing Address - Street 1:825 HARBOR BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95691
Mailing Address - Country:US
Mailing Address - Phone:916-372-8525
Mailing Address - Fax:916-372-5971
Practice Address - Street 1:825 HARBOR BLVD
Practice Address - Street 2:
Practice Address - City:WEST SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95691
Practice Address - Country:US
Practice Address - Phone:916-372-8525
Practice Address - Fax:916-372-5971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB416891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG91180-01OtherMEDICAL