=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487862280
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GARRET MADDERRA DDS, LP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2020 HURLEY WAY SUITE #290
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-929-0969
-----------------------------------------------------
Fax | 916-929-2243
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2020 HURLEY WAY SUITE #290
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95825
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-929-0969
-----------------------------------------------------
Fax | 916-929-2243
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | MRS. GAVETTE S HOFMANN
-----------------------------------------------------
Credential | RDA
-----------------------------------------------------
Telephone | 916-929-0969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 39837
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------