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General NPI Number Information
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NPI Number | 1265606487
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Entity Type | Organization
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Legal Business Name | FOLSOM DENTAL GROUP
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Dates
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Enumeration Date | 04/18/2008
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Last Update Date | 04/18/2008
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Provider Practice Location Address
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Address Line | 1840 PRAIRIE CITY RD SUITE 200
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City | FOLSOM
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State | CA
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Zip | 95630-9579
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Country | US
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Telephone | 916-351-9808
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Fax | 916-351-9847
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Provider Business Mailing Address
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Address Line | 1840 PRAIRIE CITY RD SUITE 200
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City | FOLSOM
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State | CA
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Zip | 95630-9579
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Country | US
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Telephone | 916-351-9808
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Fax | 916-351-9847
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | STEVE SAMUSENKO
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Credential |
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Telephone | 916-351-9808
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 41689
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License Number State | CA
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