Provider Demographics
NPI:1528356102
Name:LA CLINICA DE LA RAZA TRANSIENT VILLAGE
Entity type:Organization
Organization Name:LA CLINICA DE LA RAZA TRANSIENT VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ARIANE
Authorized Official - Middle Name:
Authorized Official - Last Name:TERLET
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-535-4713
Mailing Address - Street 1:3451 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-3463
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:
Practice Address - Street 1:3451 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601-3463
Practice Address - Country:US
Practice Address - Phone:510-535-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LA CLINICA DE LA RAZA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-07-15
Last Update Date:2011-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA25801302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization