=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588197156
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ALEX ANTIPOV DENTAL CORP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2017
-----------------------------------------------------
Last Update Date | 04/10/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8759 CENTER PKWY
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95823-7682
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-419-9939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 340129
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95834-0129
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-419-9939
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DENTIST
-----------------------------------------------------
Name | DR. ALEX ANTIPOV
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 916-419-9939
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number | 50724
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------