Provider Demographics
NPI:1124415658
Name:NG DENTAL CORP
Entity type:Organization
Organization Name:NG DENTAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NG
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:805-929-1888
Mailing Address - Street 1:195 N THOMPSON AVE
Mailing Address - Street 2:STE. 3
Mailing Address - City:NIPOMO
Mailing Address - State:CA
Mailing Address - Zip Code:93444-9029
Mailing Address - Country:US
Mailing Address - Phone:805-929-1888
Mailing Address - Fax:805-929-1880
Practice Address - Street 1:195 N THOMPSON AVE
Practice Address - Street 2:STE. 3
Practice Address - City:NIPOMO
Practice Address - State:CA
Practice Address - Zip Code:93444-9029
Practice Address - Country:US
Practice Address - Phone:805-929-1888
Practice Address - Fax:805-929-1880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-22
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56490122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty