=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699127779
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHRISTOPHER MUROLO DDS A PROFESSIONAL DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2016
-----------------------------------------------------
Last Update Date | 07/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1330 MEDICAL CENTER DR STE 3
-----------------------------------------------------
City | ROHNERT PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94928-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-584-7790
-----------------------------------------------------
Fax | 707-584-5056
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1330 MEDICAL CENTER DR STE 3
-----------------------------------------------------
City | ROHNERT PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94928-2901
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 707-584-7790
-----------------------------------------------------
Fax | 707-584-5056
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | DR. CHRISTOPHER ROBERT MUROLO
-----------------------------------------------------
Credential | D.D.S.
-----------------------------------------------------
Telephone | 707-584-7790
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number | 58974
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------