Healthcare Provider Details

I. General information

NPI: 1003365057
Provider Name (Legal Business Name): DHILLONDENTA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/30/2016
Last Update Date: 09/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

414 MILLBROOK CT
LINCOLN CA
95648-3250
US

IV. Provider business mailing address

414 MILLBROOK CT
LINCOLN CA
95648-3250
US

V. Phone/Fax

Practice location:
  • Phone: 916-872-0737
  • Fax:
Mailing address:
  • Phone: 916-872-0737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59097
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number59097
License Number StateCA

VIII. Authorized Official

Name: RAJWINDER SINGH DHILLON
Title or Position: DENTIST
Credential: DDS
Phone: 916-872-0737