Provider Demographics
NPI:1043822380
Name:DR. WERNER VISAGE DDS, INC.
Entity type:Organization
Organization Name:DR. WERNER VISAGE DDS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMIN LEAD
Authorized Official - Prefix:
Authorized Official - First Name:YURIY
Authorized Official - Middle Name:
Authorized Official - Last Name:TIMONICHEV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-487-1468
Mailing Address - Street 1:6440 FAIR OAKS BLVD
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-4019
Mailing Address - Country:US
Mailing Address - Phone:916-487-7148
Mailing Address - Fax:916-487-1468
Practice Address - Street 1:6440 FAIR OAKS BLVD
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-4019
Practice Address - Country:US
Practice Address - Phone:916-487-7148
Practice Address - Fax:916-487-1468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-18
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1639622848OtherNPI1