Healthcare Provider Details

I. General information

NPI: 1841019809
Provider Name (Legal Business Name): DAVID R. DATWYLER, D.D.S., A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2024
Last Update Date: 10/07/2024
Certification Date: 10/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3903 PARK DR
EL DORADO HILLS CA
95762-4561
US

IV. Provider business mailing address

3605 GRANT DR
RENO NV
89509-5301
US

V. Phone/Fax

Practice location:
  • Phone: 916-260-5213
  • Fax:
Mailing address:
  • Phone: 775-409-4614
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State

VIII. Authorized Official

Name: ALETA BEUTER
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 775-409-4614