Provider Demographics
NPI:1942098934
Name:ANDREK PMENDO INGERSOLL DENTAL CORPORATION
Entity type:Organization
Organization Name:ANDREK PMENDO INGERSOLL DENTAL CORPORATION
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 1:3300 N TRIUMPH BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:LEHI
Mailing Address - State:UT
Mailing Address - Zip Code:84043-5046
Mailing Address - Country:US
Mailing Address - Phone:707-673-7531
Mailing Address - Fax:
Practice Address - Street 1:2301 PARK MARINA DR STE 23
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2158
Practice Address - Country:US
Practice Address - Phone:530-697-0110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223E0200XDental ProvidersDentistEndodonticsGroup - Single Specialty