Provider Demographics
NPI:1750519682
Name:NORTH SHORE DENTAL LLC
Entity type:Organization
Organization Name:NORTH SHORE DENTAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO, DDS
Authorized Official - Prefix:
Authorized Official - First Name:TUONG-VAN
Authorized Official - Middle Name:B
Authorized Official - Last Name:HYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-741-2140
Mailing Address - Street 1:500 ALFRED NOBEL DR.
Mailing Address - Street 2:SUITE 240
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547
Mailing Address - Country:US
Mailing Address - Phone:510-741-2140
Mailing Address - Fax:510-741-2142
Practice Address - Street 1:500 ALFRED NOBEL DR.
Practice Address - Street 2:SUITE 240
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547
Practice Address - Country:US
Practice Address - Phone:510-741-2140
Practice Address - Fax:510-741-2142
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35608122300000X
CA45843122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty