=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598302432
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ALIX ANGELICA TORRES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/10/2019
-----------------------------------------------------
Last Update Date | 12/10/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7227 29TH ST STE C
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95822-5005
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-226-6767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3281 ROCK CREEK WAY
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95747-7155
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-356-9122
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 104595
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------