Provider Demographics
NPI:1700335932
Name:DALLA DENTAL GROUP
Entity Type:Organization
Organization Name:DALLA DENTAL GROUP
Other - Org Name:ORA DENTISTRY
Other - Org Type:Doing Business As
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:DDS
Authorized Official - Phone:646-427-6519
Mailing Address - Street 1:2733 ELK GROVE BLVD
Mailing Address - Street 2:SUITE 180
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-7165
Mailing Address - Country:US
Mailing Address - Phone:916-975-1000
Mailing Address - Fax:
Practice Address - Street 1:2733 ELK GROVE BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7165
Practice Address - Country:US
Practice Address - Phone:916-975-1000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-29
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA63130122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty