Healthcare Provider Details

I. General information

NPI: 1578575023
Provider Name (Legal Business Name): WEIDEMAN PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7916 PEBBLE BEACH DR SUITE 101
CITRUS HEIGHTS CA
95610-7790
US

IV. Provider business mailing address

7916 PEBBLE BEACH DR SUITE 101
CITRUS HEIGHTS CA
95610-7790
US

V. Phone/Fax

Practice location:
  • Phone: 916-962-0577
  • Fax:
Mailing address:
  • Phone: 916-962-0577
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number37753
License Number StateCA

VIII. Authorized Official

Name: CYNTHIA L. WEIDEMAN
Title or Position: OWNER DENTIST
Credential: D.D.S.
Phone: 916-962-0577