1063604684 NPI number — CAPITOL PERIODONTAL GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063604684 NPI number — CAPITOL PERIODONTAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAPITOL PERIODONTAL GROUP
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:
Provider Other Organization Name Type Code:
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:
1063604684
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/16/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 255747
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SACRAMENTO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
95865-5747
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
916-394-6555
Provider Business Mailing Address Fax Number:
916-394-6545

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9309 OFFICE PARK CIR
Provider Second Line Business Practice Location Address:
STE 110
Provider Business Practice Location Address City Name:
ELK GROVE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95758-8072
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
916-684-3379
Provider Business Practice Location Address Fax Number:
916-684-4106
Provider Enumeration Date:
08/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DILWORTH
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCIAL ASSISTANT
Authorized Official Telephone Number:
916-394-6555

Provider Taxonomy Codes

  • Taxonomy code: 1223P0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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