MEDICARE: CAPITOL PERIODONTAL GROUP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223P0300X	Periodontics

General Provider Information

NPI Number	:	1063604684
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPITOL PERIODONTAL GROUP

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

Provider Business Practice Location Address
First Line	:	9309 OFFICE PARK CIR
Second Line	:	STE 110
City	:	ELK GROVE
State	:	CA
Zip	:	95758-8072
Country	:	US
Telephone Number	:	916-684-3379
Fax Number	:	916-684-4106

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

Provider Enumeration Date	:	08/16/2007
Last Update Date	:	08/16/2007

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