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General NPI Number Information
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NPI Number | 1356216907
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Entity Type | Organization
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Legal Business Name | ANDREKGBORTHO INGERSOLL DENTAL CORPORATION
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Dates
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Enumeration Date | 10/06/2025
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Last Update Date | 10/06/2025
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Provider Practice Location Address
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Address Line | 4150 DOUGLAS BLVD STE B
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City | GRANITE BAY
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State | CA
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Zip | 95746-5908
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Country | US
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Telephone | 916-774-6986
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Fax |
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Provider Business Mailing Address
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Address Line | 3300 N TRIUMPH BLVD STE 100
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City | LEHI
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State | UT
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Zip | 84043-5046
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Country | US
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Telephone | 707-673-7531
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Fax |
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Authorized Official
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Title or Position | DIRECTOR OF OPERATIONS
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Name | LEEANN BLAZER
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Credential |
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Telephone | 707-673-7531
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223X0400X
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Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
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License Number |
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License Number State |
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