Provider Demographics
NPI:1063874329
Name:DENTISTAR COMPREHENSIVE DENTAL CARE, INC.
Entity type:Organization
Organization Name:DENTISTAR COMPREHENSIVE DENTAL CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:G
Authorized Official - Last Name:KIM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-963-1316
Mailing Address - Street 1:111 DEERWOOD RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4409
Mailing Address - Country:US
Mailing Address - Phone:925-718-8970
Mailing Address - Fax:925-718-8971
Practice Address - Street 1:111 DEERWOOD RD
Practice Address - Street 2:SUITE 350
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4409
Practice Address - Country:US
Practice Address - Phone:925-718-8970
Practice Address - Fax:925-718-8971
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA586191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty