Healthcare Provider Details

I. General information

NPI: 1902173206
Provider Name (Legal Business Name): ROBERT MCCLURG, DDS A PROFESSIONAL DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8689 FOLSOM BLVD
SACRAMENTO CA
95826-3708
US

IV. Provider business mailing address

8689 FOLSOM BLVD
SACRAMENTO CA
95826-3708
US

V. Phone/Fax

Practice location:
  • Phone: 916-381-7171
  • Fax: 916-381-1171
Mailing address:
  • Phone: 916-381-7171
  • Fax: 916-381-1171

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number25945
License Number StateCA

VIII. Authorized Official

Name: MRS. MARISSA MCCLURG
Title or Position: BUSINESS MANAGER
Credential:
Phone: 916-381-7171