=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477884641
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PRODENT DENTAL LAB
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/27/2010
-----------------------------------------------------
Last Update Date | 01/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3000 ALAMO DR STE 108
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95687-6345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-655-8824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3000 ALAMO DR STE 108
-----------------------------------------------------
City | VACAVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95687-6345
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-655-8824
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | LAB TECHNICIAN
-----------------------------------------------------
Name | MR. PERCIVAL MAGPUSAO MANZANO
-----------------------------------------------------
Credential | MDT
-----------------------------------------------------
Telephone | 707-655-8824
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 292200000X
-----------------------------------------------------
Taxonomy Name | Dental Laboratory
-----------------------------------------------------
License Number | 016761
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------