Healthcare Provider Details

I. General information

NPI: 1932650249
Provider Name (Legal Business Name): MARIA TERESA R DE GUZMAN DDS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2016
Last Update Date: 10/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 SUNRISE BLVD SUITE A1
FAIR OAKS CA
95628-4944
US

IV. Provider business mailing address

5060 SUNRISE BLVD STE A4
FAIR OAKS CA
95628-4944
US

V. Phone/Fax

Practice location:
  • Phone: 916-863-0456
  • Fax: 916-910-0751
Mailing address:
  • Phone: 916-910-0708
  • Fax: 916-910-0751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number41390
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number41390
License Number StateCA

VIII. Authorized Official

Name: MR. ANTHONY E DEGUZMAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 916-919-5721