=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295062503
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WOODCREEK DENTISTRY INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2009
-----------------------------------------------------
Last Update Date | 11/06/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7456 FOOTHILLS BLVD STE 14
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95747-6562
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-773-0800
-----------------------------------------------------
Fax | 916-773-0835
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7456 FOOTHILLS BLVD. #14
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95747
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-773-0800
-----------------------------------------------------
Fax | 916-773-0835
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BRIAN KENNETH RALLI
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 916-773-0800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 47828
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 47783
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------