Provider Demographics
NPI:1225861297
Name:MARY LOU GAERLAN DDS DENTAL CORP
Entity type:Organization
Organization Name:MARY LOU GAERLAN DDS DENTAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:DONN
Authorized Official - Middle Name:
Authorized Official - Last Name:MANALILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-631-5994
Mailing Address - Street 1:4757 MANGELS BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-4175
Mailing Address - Country:US
Mailing Address - Phone:707-864-1010
Mailing Address - Fax:707-864-8051
Practice Address - Street 1:4757 MANGELS BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-4175
Practice Address - Country:US
Practice Address - Phone:707-864-1010
Practice Address - Fax:707-864-8051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-23
Last Update Date:2024-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty