Healthcare Provider Details

I. General information

NPI: 1487488060
Provider Name (Legal Business Name): DR ANDREK GV INGERSOLL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2024
Last Update Date: 08/27/2024
Certification Date: 08/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 W EMPIRE ST
GRASS VALLEY CA
95945-7510
US

IV. Provider business mailing address

115 W EMPIRE ST
GRASS VALLEY CA
95945-7510
US

V. Phone/Fax

Practice location:
  • Phone: 530-478-8366
  • Fax:
Mailing address:
  • Phone: 530-478-8366
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ANDREK INGERSOLL
Title or Position: OWNER
Credential: DMD
Phone: 919-656-3004