Healthcare Provider Details

I. General information

NPI: 1225701972
Provider Name (Legal Business Name): PEBBLE BEACH DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/28/2021
Last Update Date: 07/28/2021
Certification Date: 07/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7916 PEBBLE BEACH DR STE 206
CITRUS HEIGHTS CA
95610-7790
US

IV. Provider business mailing address

7916 PEBBLE BEACH DR STE 206
CITRUS HEIGHTS CA
95610-7790
US

V. Phone/Fax

Practice location:
  • Phone: 916-961-2180
  • Fax:
Mailing address:
  • Phone: 916-961-2180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRANDON ERICKSON
Title or Position: DENTIST
Credential: DDS
Phone: 916-961-2180