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General NPI Number Information
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NPI Number | 1255502522
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Entity Type | Organization
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Legal Business Name | NANCY DERHAM DENTAL CORPORATION
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Dates
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Enumeration Date | 03/14/2008
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Last Update Date | 03/14/2008
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Provider Practice Location Address
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Address Line | 1805 NOVATO BLVD #6
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City | NOVATO
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State | CA
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Zip | 94947-2934
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Country | US
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Telephone | 415-892-4721
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Fax | 415-892-5921
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Provider Business Mailing Address
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Address Line | 1805 NOVATO BLVD #6
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City | NOVATO
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State | CA
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Zip | 94947-2934
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Country | US
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Telephone | 415-892-4721
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Fax | 415-892-5921
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Authorized Official
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Title or Position | PRESIDENT
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Name | NANCY DERHAM
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Credential | DDS
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Telephone | 415-892-4721
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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 | 38914
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License Number State | CA
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