Provider Demographics
NPI:1356216907
Name:ANDREKGBORTHO INGERSOLL DENTAL CORPORATION
Entity type:Organization
Organization Name:ANDREKGBORTHO INGERSOLL DENTAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:LEEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-673-7531
Mailing Address - Street 1:3300 N TRIUMPH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5046
Mailing Address - Country:US
Mailing Address - Phone:707-673-7531
Mailing Address - Fax:
Practice Address - Street 1:4150 DOUGLAS BLVD STE B
Practice Address - Street 2:
Practice Address - City:GRANITE BAY
Practice Address - State:CA
Practice Address - Zip Code:95746-5908
Practice Address - Country:US
Practice Address - Phone:916-774-6986
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-10-06
Last Update Date:2025-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Single Specialty