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Provider Information for 1073971461

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1073971461

Calendar   Last Updated:  2016-10-04
  Certification Date: 


Name Value
NPI 1073971461
Enumeration Date 2016-02-01
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 655 HILLTOP DR APT 102
REDDING, CA 96003-3735
United States

Phone: 607-765-7675 | Fax:
View Map External Link
Primary Practice Address 2500 MAIN ST
RED BLUFF, CA 96080-2336
United States

Phone: 530-529-2567 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Primary Taxonomy Selected Taxonomy State License Number
Yes 122300000X - Dentist CA 100886