Provider Demographics
NPI:1881806339
Name:EVERGREEN FAMILY DENTISTRY
Entity type:Organization
Organization Name:EVERGREEN FAMILY DENTISTRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:DEE
Authorized Official - Last Name:KRANT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:530-842-2558
Mailing Address - Street 1:310 EVERGREEN LN
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-3203
Mailing Address - Country:US
Mailing Address - Phone:530-842-2558
Mailing Address - Fax:530-842-9011
Practice Address - Street 1:310 EVERGREEN LN
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-3203
Practice Address - Country:US
Practice Address - Phone:530-842-2558
Practice Address - Fax:530-842-9011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-05
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA384401223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty