Healthcare Provider Details

I. General information

NPI: 1053964072
Provider Name (Legal Business Name): JOHN C. TRUEB, DDS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/18/2019
Last Update Date: 08/26/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 SAINT DOMINICS DR STE 100
MANTECA CA
95337-7802
US

IV. Provider business mailing address

165 SAINT DOMINICS DR STE 100
MANTECA CA
95337-7802
US

V. Phone/Fax

Practice location:
  • Phone: 209-823-3574
  • Fax: 209-239-4378
Mailing address:
  • Phone: 209-823-3574
  • Fax: 209-239-4378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: JOHN CHARLES TRUEB
Title or Position: OWNER
Credential: DDS
Phone: 209-823-3574