Healthcare Provider Details

I. General information

NPI: 1982964656
Provider Name (Legal Business Name): MICHAEL SYCAMORE DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 05/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1189 ROADRUNNER WAY
SIMI VALLEY CA
93065-3159
US

IV. Provider business mailing address

4209 VIA ARBOLADA UNIT 134
LOS ANGELES CA
90042-5094
US

V. Phone/Fax

Practice location:
  • Phone: 626-808-3793
  • Fax:
Mailing address:
  • Phone: 626-808-3793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number59942
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL SYCAMORE
Title or Position: PRESIDENT
Credential: DDS
Phone: 626-808-3793