=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831748839
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SLATE DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2019
-----------------------------------------------------
Last Update Date | 09/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6512 LONETREE BLVD STE 100
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-5883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-780-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6512 LONETREE BLVD STE 100
-----------------------------------------------------
City | ROCKLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95765-5883
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-780-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. DARCE SLATE
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 916-780-1000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223S0112X
-----------------------------------------------------
Taxonomy Name | Oral and Maxillofacial Surgery (Dentist)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------