Healthcare Provider Details

I. General information

NPI: 1235312463
Provider Name (Legal Business Name): JOHN MACIEL JR. DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PRISON ROAD CALIFORNIA STATE PRISON SACRAMENTO
REPRESA CA
95671
US

IV. Provider business mailing address

100 PRISON ROAD CALIFORNIA STATE PRISON SACRAMENTO
REPRESA CA
95671
US

V. Phone/Fax

Practice location:
  • Phone: 916-985-8610
  • Fax:
Mailing address:
  • Phone: 916-985-8610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number033333
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: