MEDICARE: UNIVERSITY CALIFORNIA DAVIS MEDICAL CENTER, UNIVERSITY DENTAL ASSOC

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	1223P0700X	Prosthodontics	23361	CA

General Provider Information

NPI Number	:	1316944465
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	UNIVERSITY CALIFORNIA DAVIS MEDICAL CENTER, UNIVERSITY DENTAL ASSOC

Provider Business Mailing Address
First Line	:	2521 STOCKTON BLVD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-2207
Country	:	US
Telephone Number	:	916-734-5408
Fax Number	:	916-734-1299

Provider Business Practice Location Address
First Line	:	2521 STOCKTON BLVD
Second Line	:
City	:	SACRAMENTO
State	:	CA
Zip	:	95817-2207
Country	:	US
Telephone Number	:	916-734-5408
Fax Number	:	916-734-1299

Authorized Official
Title or Position	:	DIRECTOR DENTAL CLINIC
Name	:	DR. ROBERT LYONS
Credential	:	DDS
Telephone Number	:	916-734-5408

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	08/22/2020

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