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General NPI Number Information
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NPI Number | 1245443670
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Entity Type | Organization
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Legal Business Name | NEEDHAM DENTAL CORPORATION
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Dates
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Enumeration Date | 05/08/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 847 SAN PABLO AVE
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City | ALBANY
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State | CA
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Zip | 94706-1602
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Country | US
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Telephone | 510-528-7216
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Fax | 510-528-7217
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Provider Business Mailing Address
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Address Line | 236 N SANTA CRUZ AVE UNIT 225
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City | LOS GATOS
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State | CA
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Zip | 95030-7244
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Country | US
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Telephone | 408-354-8549
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Fax | 408-354-8649
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Authorized Official
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Title or Position | DENTAL DIRECTOR
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Name | DR. ANTHONY JOHN NEEDHAM
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Credential | DDS
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Telephone | 408-354-8549
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 50653
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License Number State | CA
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