Healthcare Provider Details

I. General information

NPI: 1225124969
Provider Name (Legal Business Name): PETER RALPH VANDERSLOOT D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2850 N TRACY BLVD SUITE #102
TRACY CA
95376-7767
US

IV. Provider business mailing address

2850 N TRACY BLVD SUITE #102
TRACY CA
95376-7767
US

V. Phone/Fax

Practice location:
  • Phone: 209-835-3933
  • Fax: 209-835-3939
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number46707
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: