Healthcare Provider Details

I. General information

NPI: 1568549541
Provider Name (Legal Business Name): COLUMBIA-ARORA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

599 TOMALES RD
PETALUMA CA
94952-5002
US

IV. Provider business mailing address

6490 FRONT ST #207
FORESTVILLE CA
95436-9604
US

V. Phone/Fax

Practice location:
  • Phone: 707-765-7234
  • Fax:
Mailing address:
  • Phone: 707-765-7234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License NumberRDA47476
License Number StateCA

VIII. Authorized Official

Name: MR. ROBERT FLOYD WILSON JR.
Title or Position: RDA DENTAL ASST
Credential: RDA
Phone: 707-765-7234