MEDICARE: MRS. NANCY DERHAM DDS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	38914	CA

General Provider Information

NPI Number	:	1285805721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NANCY DERHAM DDS

Provider Business Mailing Address
First Line	:	1805 NOVATO BLVD
Second Line	:	SUITE 6
City	:	NOVATO
State	:	CA
Zip	:	94947-2934
Country	:	US
Telephone Number	:	415-892-4721
Fax Number	:	415-892-5921

Provider Business Practice Location Address
First Line	:	1805 NOVATO BLVD
Second Line	:	SUITE 6
City	:	NOVATO
State	:	CA
Zip	:	94947-2934
Country	:	US
Telephone Number	:	415-892-4721
Fax Number	:	415-892-5921

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	03/12/2008

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