Basic Information
| Provider Information | |||||||||
| NPI: | 1225437353 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACCESS PROFESSIONAL DENTAL CARE,LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | BLUE HILLS DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 8890 CAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958263200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169225000 | ||||||||
| FaxNumber: | 9166469000 | ||||||||
| Practice Location | |||||||||
| Address1: | 6540 S STATE ST | ||||||||
| Address2: | |||||||||
| City: | MURRAY | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841077219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8015908466 | ||||||||
| FaxNumber: | 8019051934 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2014 | ||||||||
| LastUpdateDate: | 09/09/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DETRICK | ||||||||
| AuthorizedOfficialFirstName: | LORRI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9165636002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.