Healthcare Provider Details

I. General information

NPI: 1285862904
Provider Name (Legal Business Name): PAOLO POIDMORE DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2009
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9197 GREENBACK LN STE B
ORANGEVALE CA
95662-4792
US

IV. Provider business mailing address

9197 GREENBACK LN STE B
ORANGEVALE CA
95662-4792
US

V. Phone/Fax

Practice location:
  • Phone: 916-988-1744
  • Fax: 916-989-2187
Mailing address:
  • Phone: 916-988-1744
  • Fax: 916-989-2187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number58354
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: