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General NPI Number Information
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NPI Number | 1194212134
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Entity Type | Organization
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Legal Business Name | TOOTH SPA DENTISTRY
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Dates
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Enumeration Date | 04/16/2018
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Last Update Date | 04/16/2018
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Provider Practice Location Address
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Address Line | 831 STERLING PKWY STE 130
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City | LINCOLN
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State | CA
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Zip | 95648-7323
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Country | US
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Telephone | 916-209-3708
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Fax | 888-858-1377
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Provider Business Mailing Address
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Address Line | 831 STERLING PKWY STE 130
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City | LINCOLN
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State | CA
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Zip | 95648-7323
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Country | US
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Telephone | 916-209-3708
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Fax | 888-858-1377
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Authorized Official
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Title or Position | OWNER, DENTIST
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Name | IRENE M HERMO
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Credential | DDS
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Telephone | 916-209-3708
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QD0000X
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Taxonomy Name | Dental Clinic/Center
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License Number | 58867
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License Number State | CA
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