Healthcare Provider Details

I. General information

NPI: 1285833442
Provider Name (Legal Business Name): JUSTIN SYCAMORE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 12/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 E THOUSAND OAKS BLVD
THOUSAND OAKS CA
91360-6054
US

IV. Provider business mailing address

324 GALSWORTHY ST
THOUSAND OAKS CA
91360-5313
US

V. Phone/Fax

Practice location:
  • Phone: 805-777-0050
  • Fax:
Mailing address:
  • Phone: 805-908-5817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number59913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: