Healthcare Provider Details

I. General information

NPI: 1639389927
Provider Name (Legal Business Name): PICKETT DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 ROTARY WAY
VALLEJO CA
94591-8475
US

IV. Provider business mailing address

25 ROTARY WAY
VALLEJO CA
94591-8475
US

V. Phone/Fax

Practice location:
  • Phone: 707-642-2800
  • Fax: 707-642-1839
Mailing address:
  • Phone: 707-642-2800
  • Fax: 707-642-1839

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number32757
License Number StateCA

VIII. Authorized Official

Name: DR. STEVEN PICKETT
Title or Position: PRESIDENT
Credential: DDS
Phone: 707-642-2800