Healthcare Provider Details

I. General information

NPI: 1700269982
Provider Name (Legal Business Name): ALEXANDER VILDERMAN DENTAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2015
Last Update Date: 07/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 HARBOR BLVD
WEST SACRAMENTO CA
95691-2201
US

IV. Provider business mailing address

825 HARBOR BLVD
WEST SACRAMENTO CA
95691-2201
US

V. Phone/Fax

Practice location:
  • Phone: 916-372-8525
  • Fax: 916-372-5971
Mailing address:
  • Phone: 916-372-8525
  • Fax: 916-372-5971

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number40753
License Number StateCA

VIII. Authorized Official

Name: ALEXANDER VILDERMAN
Title or Position: OWNER
Credential:
Phone: 916-372-8525