Provider Demographics
NPI:1942774989
Name:HERCULES DENTAL CARE IN FREMONT
Entity type:Organization
Organization Name:HERCULES DENTAL CARE IN FREMONT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:LIN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-741-1777
Mailing Address - Street 1:500 ALFRED NOBEL DR STE 130
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1839
Mailing Address - Country:US
Mailing Address - Phone:510-741-1777
Mailing Address - Fax:
Practice Address - Street 1:556 MOWRY AVE STE 203
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4186
Practice Address - Country:US
Practice Address - Phone:510-791-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DOUGLAS LIN DDS INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-01-13
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1689904476Medicaid