=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932276003
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVATO FAMILY DENTAL CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/30/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7460 REDWOOD BLVD
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94945-2457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-897-3914
-----------------------------------------------------
Fax | 415-898-6677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7460 REDWOOD BLVD
-----------------------------------------------------
City | NOVATO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94945-2457
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-897-3914
-----------------------------------------------------
Fax | 415-898-6677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | JOYCE VIZZA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 415-897-3914
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 46590
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 43841
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------