Healthcare Provider Details

I. General information

NPI: 1487031027
Provider Name (Legal Business Name): MARIA TERESA R DE GUZMAN DDS CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2436 PROFESSIONAL DR SUITE 200
ROSEVILLE CA
95661-7779
US

IV. Provider business mailing address

5060 SUNRISE BLVD SUITE A3
FAIR OAKS CA
95628-4944
US

V. Phone/Fax

Practice location:
  • Phone: 916-774-9920
  • Fax: 916-910-0752
Mailing address:
  • Phone: 916-919-5721
  • Fax: 916-910-0751

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number41390
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number41390
License Number StateCA

VIII. Authorized Official

Name: ANTHONY ESCANO DEGUZMAN SR.
Title or Position: ADMINISTARTOR
Credential:
Phone: 916-919-5721