Healthcare Provider Details

I. General information

NPI: 1720133796
Provider Name (Legal Business Name): PARKSIDE DENTAL CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1325 TRAVIS BLVD
FAIRFIELD CA
94533-4611
US

IV. Provider business mailing address

1325 TRAVIS BLVD
FAIRFIELD CA
94533-4611
US

V. Phone/Fax

Practice location:
  • Phone: 707-427-2222
  • Fax: 707-427-0562
Mailing address:
  • Phone: 707-427-2222
  • Fax: 707-427-0562

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number48710
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number28479
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number27964
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number30117
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number51677
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number49443
License Number StateCA
# 7
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number19300
License Number StateCA
# 8
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number45580
License Number StateCA

VIII. Authorized Official

Name: MRS. AVRIL MAY ALTMAN
Title or Position: INSURANCE COORDINATOR
Credential:
Phone: 707-427-2222