MEDICARE: SPRAGUE, PACKHAM & PIZZA DENTAL CORPORATION

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	1223G0001X	General Practice Dentistry	29105	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	850412 & 781138	OTHER	CA	UNITED CONCORDIA

General Provider Information

NPI Number	:	1225168156
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPRAGUE, PACKHAM & PIZZA DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	4027 MISSION OAKS BLVD
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-5156
Country	:	US
Telephone Number	:	805-484-1022
Fax Number	:	805-484-3221

Provider Business Practice Location Address
First Line	:	4027 MISSION OAKS BLVD
Second Line	:
City	:	CAMARILLO
State	:	CA
Zip	:	93012-5156
Country	:	US
Telephone Number	:	805-484-1022
Fax Number	:	805-484-3221

Authorized Official
Title or Position	:	DENTIST CEO
Name	:	DR. ROBERT W SPRAGUE
Credential	:	DDS
Telephone Number	:	805-484-1022

Provider Enumeration Date	:	03/07/2007
Last Update Date	:	10/20/2014

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