Provider Demographics
NPI:1417767161
Name:DENTAL OFFICE OF ANDREK J INGERSOLL
Entity type:Organization
Organization Name:DENTAL OFFICE OF ANDREK J INGERSOLL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:LEEANN
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAZER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-673-7531
Mailing Address - Street 1:585 TAHOE KEYS BLVD STE 2
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-3371
Mailing Address - Country:US
Mailing Address - Phone:530-541-3772
Mailing Address - Fax:
Practice Address - Street 1:585 TAHOE KEYS BLVD STE 2
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-3371
Practice Address - Country:US
Practice Address - Phone:530-541-3772
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-01-13
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental