MEDICARE: A PROFESSIONAL DENTAL CORP.

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	40072	CA

General Provider Information

NPI Number	:	1639174279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A PROFESSIONAL DENTAL CORP.

Provider Business Mailing Address
First Line	:	3505 LONE TREE WAY
Second Line	:	STE 7
City	:	ANTIOCH
State	:	CA
Zip	:	94509-6067
Country	:	US
Telephone Number	:	925-756-7884
Fax Number	:	925-756-7894

Provider Business Practice Location Address
First Line	:	3505 LONE TREE WAY
Second Line	:	STE 7
City	:	ANTIOCH
State	:	CA
Zip	:	94509-6067
Country	:	US
Telephone Number	:	925-756-7884
Fax Number	:	925-756-7894

Authorized Official
Title or Position	:	OFFICE MANAGER
Name	:	MRS. KELLY ANN BUTTI
Credential	:
Telephone Number	:	925-756-7884

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	06/13/2008

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