Healthcare Provider Details

I. General information

NPI: 1780825968
Provider Name (Legal Business Name): DOUGLAS ALAN GEDESTAD D.M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 03/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2409 L ST SUITE 1
SACRAMENTO CA
95816-5025
US

IV. Provider business mailing address

2409 L ST SUITE 1
SACRAMENTO CA
95816-5025
US

V. Phone/Fax

Practice location:
  • Phone: 916-448-1444
  • Fax: 916-447-2125
Mailing address:
  • Phone: 916-448-1444
  • Fax: 916-447-2125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number28555
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: