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General NPI Number Information
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NPI Number | 1679647762
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Entity Type | Organization
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Legal Business Name | SCEVILLE DENTAL GROUP
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Dates
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Enumeration Date | 11/20/2006
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Last Update Date | 12/23/2019
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Provider Practice Location Address
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Address Line | 1390 W H ST SUITE D-1
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City | OAKDALE
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State | CA
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Zip | 95361-3570
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Country | US
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Telephone | 209-847-8091
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Fax | 209-847-3314
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Provider Business Mailing Address
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Address Line | 1390 W H ST STE D
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City | OAKDALE
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State | CA
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Zip | 95361-3529
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Country | US
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Telephone | 209-847-8091
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Fax | 209-847-3314
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Authorized Official
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Title or Position | OWNER
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Name | JEFFERY SCEVILLE
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Credential |
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Telephone | 209-847-8091
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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 | 46428
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 122300000X
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Taxonomy Name | Dentist
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License Number | 51300
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License Number State | CA
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