Basic Information
Provider Information
NPI: 1730631086
EntityType: 2
ReplacementNPI:  
OrganizationName: NORTH VALLEY DENTAL
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 770 MASON ST STE 110
Address2:  
City: VACAVILLE
State: CA
PostalCode: 956884648
CountryCode: US
TelephoneNumber: 7074471010
FaxNumber:  
Practice Location
Address1: 770 MASON ST STE 110
Address2:  
City: VACAVILLE
State: CA
PostalCode: 956884648
CountryCode: US
TelephoneNumber: 7074471010
FaxNumber:  
Other Information
ProviderEnumerationDate: 11/02/2016
LastUpdateDate: 11/02/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: PEDERSEN
AuthorizedOfficialFirstName: WAYNE
AuthorizedOfficialMiddleName: N
AuthorizedOfficialTitleorPosition: OWNER
AuthorizedOfficialTelephone: 7074471010
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: D.D.S.
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
122300000X64725CAN193400000X MULTIPLE SINGLE SPECIALTY GROUPDental ProvidersDentist 
122300000X31510CAY193400000X MULTIPLE SINGLE SPECIALTY GROUPDental ProvidersDentist 

No ID Information.


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