Provider Demographics
NPI:1336860253
Name:DALLA DENTAL GROUP FAIRFIELD INC
Entity Type:Organization
Organization Name:DALLA DENTAL GROUP FAIRFIELD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DEVAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DALLA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:646-427-6519
Mailing Address - Street 1:3108 E PINTAIL WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-8206
Mailing Address - Country:US
Mailing Address - Phone:646-546-6374
Mailing Address - Fax:
Practice Address - Street 1:2750 N TEXAS ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-1290
Practice Address - Country:US
Practice Address - Phone:707-422-8282
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental