Healthcare Provider Details

I. General information

NPI: 1639537863
Provider Name (Legal Business Name): PAOLO A POIDMORE, DDS, MSD, A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2016
Last Update Date: 11/13/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9197 GREENBACK LN STE B
ORANGEVALE CA
95662-4792
US

IV. Provider business mailing address

3075 BEACON BLVD
WEST SACRAMENTO CA
95691-3462
US

V. Phone/Fax

Practice location:
  • Phone: 916-989-2187
  • Fax: 916-989-2187
Mailing address:
  • Phone: 916-259-9255
  • Fax:

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: PAOLO A POIDMORE
Title or Position: OWNER
Credential: DDS, MSD
Phone: 916-259-9255