Healthcare Provider Details

I. General information

NPI: 1366908618
Provider Name (Legal Business Name): CAPITOL PERIODONTAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2019
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 F STREET #5
DAVIS CA
95616
US

IV. Provider business mailing address

9309 OFFICE PARK CIRCLE, SUITE 120
ELK GROVE CA
95758
US

V. Phone/Fax

Practice location:
  • Phone: 530-756-6087
  • Fax: 530-756-5688
Mailing address:
  • Phone: 916-691-1050
  • Fax: 916-691-1066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State

VIII. Authorized Official

Name: RENEE BLAKE
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 916-691-1050