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General NPI Number Information
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NPI Number | 1578760096
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Entity Type | Organization
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Legal Business Name | COUNTRY CLUB DENTAL CARE
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Dates
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Enumeration Date | 06/28/2007
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 2237 PARK TOWNE CIR STE 3
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City | SACRAMENTO
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State | CA
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Zip | 95825-0417
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Country | US
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Telephone | 916-483-6161
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Fax | 916-480-0211
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Provider Business Mailing Address
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Address Line | 2237 PARK TOWNE CIR STE 3
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City | SACRAMENTO
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State | CA
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Zip | 95825-0417
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Country | US
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Telephone | 916-483-6161
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Fax | 916-480-0211
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Authorized Official
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Title or Position | OFFICE MANGER
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Name | MRS. PIA S SPECTOR
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Credential |
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Telephone | 916-483-6161
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 33153
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License Number State | CA
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