1932561453 NPI number — SATTOUT AND ALASWAD DENTAL CORP.

Table of content: JARROD MADDOX OTD, OTR, CHT (NPI 1114640182)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1932561453 NPI number — SATTOUT AND ALASWAD DENTAL CORP.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SATTOUT AND ALASWAD DENTAL CORP.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NONE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1932561453
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
740 W KETTLEMAN LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LODI
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95240-6051
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8851 GREENBACK LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ORANGEVALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95662-4058
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-988-5559
Provider Business Practice Location Address Fax Number:
916-988-5936
Provider Enumeration Date:
03/23/2016

Additional Information

Authorized Official

Authorized Official Last Name:
SATTOUT
Authorized Official First Name:
OMAR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
909-248-8417

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  63154 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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