Provider Demographics
NPI:1154999134
Name:TAMAL VISTA FAMILY DENTISTRY
Entity type:Organization
Organization Name:TAMAL VISTA FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:ERIC
Authorized Official - Last Name:SCOTT
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-453-4720
Mailing Address - Street 1:1447 4TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-2811
Mailing Address - Country:US
Mailing Address - Phone:415-453-4720
Mailing Address - Fax:415-453-4727
Practice Address - Street 1:1447 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2811
Practice Address - Country:US
Practice Address - Phone:415-453-4720
Practice Address - Fax:415-453-4727
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-06-15
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental