Provider Demographics
NPI:1285805721
Name:DERHAM, NANCY (DDS)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:
Last Name:DERHAM
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 NOVATO BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94947-2934
Mailing Address - Country:US
Mailing Address - Phone:415-892-4721
Mailing Address - Fax:415-892-5921
Practice Address - Street 1:1805 NOVATO BLVD
Practice Address - Street 2:SUITE 6
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94947-2934
Practice Address - Country:US
Practice Address - Phone:415-892-4721
Practice Address - Fax:415-892-5921
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA389141223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice