Basic Information
| Provider Information | |||||||||
| NPI: | 1326467168 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ACCESS PROFESSIONAL DENTAL CARE,LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | BLUE HILLS DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8890 CAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958263200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9169225000 | ||||||||
| FaxNumber: | 9166469000 | ||||||||
| Practice Location | |||||||||
| Address1: | 4115 RIVERDALE RD STE B | ||||||||
| Address2: | |||||||||
| City: | RIVERDALE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 844053509 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8019405555 | ||||||||
| FaxNumber: | 3852068383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2014 | ||||||||
| LastUpdateDate: | 09/10/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DETRICK | ||||||||
| AuthorizedOfficialFirstName: | LORRI | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 9165636002 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | UT | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
No ID Information.