Healthcare Provider Details

I. General information

NPI: 1679591556
Provider Name (Legal Business Name): THAIS CARVALHO BOOMS DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 05/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1258 COLOMA WAY
ROSEVILLE CA
95661
US

IV. Provider business mailing address

1258 COLOMA WAY
ROSEVILLE CA
95661-4602
US

V. Phone/Fax

Practice location:
  • Phone: 916-784-1144
  • Fax:
Mailing address:
  • Phone: 916-784-1144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number2901018203
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number54466
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: