Healthcare Provider Details

I. General information

NPI: 1548525785
Provider Name (Legal Business Name): DONGJIN SAH DDS, MSD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 08/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N DUTTON AVE STE 11
SANTA ROSA CA
95401-4644
US

IV. Provider business mailing address

1400 N DUTTON AVE STE 11
SANTA ROSA CA
95401-4644
US

V. Phone/Fax

Practice location:
  • Phone: 707-545-4104
  • Fax: 707-545-9668
Mailing address:
  • Phone: 707-545-4104
  • Fax: 707-545-9668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number61419
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: