Provider Demographics
NPI:1124763271
Name:DENTRUST, P.C.
Entity type:Organization
Organization Name:DENTRUST, P.C.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:EVANS
Authorized Official - Last Name:LANCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-728-9767
Mailing Address - Street 1:461 SKYMASTER CIR BLDG 648
Mailing Address - Street 2:
Mailing Address - City:TRAVIS AFB
Mailing Address - State:CA
Mailing Address - Zip Code:94535-1909
Mailing Address - Country:US
Mailing Address - Phone:707-474-4599
Mailing Address - Fax:707-402-6535
Practice Address - Street 1:461 SKYMASTER CIR BLDG 648
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1909
Practice Address - Country:US
Practice Address - Phone:707-474-4599
Practice Address - Fax:707-402-6535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty