Healthcare Provider Details

I. General information

NPI: 1376933770
Provider Name (Legal Business Name): SAINT HELENA DENTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2015
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1485 MAIN ST
SAINT HELENA CA
94574-1850
US

IV. Provider business mailing address

1485 MAIN ST
SAINT HELENA CA
94574-1850
US

V. Phone/Fax

Practice location:
  • Phone: 707-963-2339
  • Fax:
Mailing address:
  • Phone: 707-963-2339
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27125
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number51677
License Number StateCA

VIII. Authorized Official

Name: PAULINE DEMETRAKOPULOS
Title or Position: SOLE PROPRIETOR
Credential: DDS
Phone: 707-963-2321