MEDICARE: ROYTMAN DENTAL CORPORATION

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	1223G0001X	General Practice Dentistry	46523	CA

General Provider Information

NPI Number	:	1720043961
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ROYTMAN DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	555 W BENJAMIN HOLT DR
Second Line	:	BLDG. B
City	:	STOCKTON
State	:	CA
Zip	:	95207-3839
Country	:	US
Telephone Number	:	209-476-4700
Fax Number	:	209-478-8758

Provider Business Practice Location Address
First Line	:	2494 MISSION ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94110-2415
Country	:	US
Telephone Number	:	415-821-1200
Fax Number	:	415-821-0537

Authorized Official
Title or Position	:	CREDENTIALING COORDINATOR
Name	:	MRS. FAITH RAMIENTOS TABUJARA
Credential	:
Telephone Number	:	209-476-4728

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	08/22/2020

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