=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104313030
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DR. SYED S.RIZVI DDS. A PROFESSIONAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2018
-----------------------------------------------------
Last Update Date | 08/14/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 940 N CENTER ST
-----------------------------------------------------
City | STOCKTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-922-1983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 LONE OAK DR
-----------------------------------------------------
City | PLEASANTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94566-7662
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 209-922-1983
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. SYED SAJJAD RIZVI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 209-922-1983
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 57825
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------