Organization
EVERGREEN PLAZA DENTAL, INC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
PATRICK CARNEY DDS (PRESIDENT)
(707) 964-4759
Entity
Organization
Contact information
Practice address
45160 MAIN ST, MENDOCINO, CA 95460-2477
(707) 964-4759
Mailing address
PO BOX 2477, MENDOCINO, CA 95460-2477
(707) 964-4759
Taxonomy
Speciality
Code
Description
License number
State
261QD0000X
Dental Clinic/Center
Primary
27738
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
27738
DENTAL LICENSE
CA
Enumeration date
03/20/2007
Last updated
09/12/2009
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