Provider Demographics
NPI:1457926057
Name:PHEN DENTAL PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PHEN DENTAL PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:PHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-337-5158
Mailing Address - Street 1:109 FERRARI RANCH RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-7423
Mailing Address - Country:US
Mailing Address - Phone:916-253-7000
Mailing Address - Fax:
Practice Address - Street 1:109 FERRARI RANCH RD STE 100
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-7423
Practice Address - Country:US
Practice Address - Phone:916-253-7000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental