MEDICARE: DR. IMMANUEL UGONNIA SELASSIE I

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	122300000X	Dentist	56829	CA

General Provider Information

NPI Number	:	1053601039
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IMMANUEL UGONNIA SELASSIE I

Provider Business Mailing Address
First Line	:	2322 FRUITVALE AVE
Second Line	:
City	:	OAKLAND
State	:	CA
Zip	:	94601-2534
Country	:	US
Telephone Number	:	510-520-4327
Fax Number	:

Provider Business Practice Location Address
First Line	:	2430 FAIR OAKS BLVD (APT 120)
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95825-5129
Country	:	US
Telephone Number	:	206-384-6915
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2011
Last Update Date	:	02/28/2014

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