Healthcare Provider Details

I. General information

NPI: 1992376842
Provider Name (Legal Business Name): KEVIN KENJI O'BRIEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2021
Last Update Date: 07/01/2021
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 SECRET RIVER DR
SACRAMENTO CA
95831-3465
US

IV. Provider business mailing address

925 SECRET RIVER DR
SACRAMENTO CA
95831-3465
US

V. Phone/Fax

Practice location:
  • Phone: 916-391-9200
  • Fax:
Mailing address:
  • Phone: 916-391-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106419
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number106419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: