MEDICARE: WEIDEMAN PROFESSIONAL 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	1223P0221X	Pediatric Dentistry	37753	CA

General Provider Information

NPI Number	:	1578575023
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WEIDEMAN PROFESSIONAL DENTAL CORPORATION

Provider Business Mailing Address
First Line	:	7916 PEBBLE BEACH DR
Second Line	:	SUITE 101
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95610-7790
Country	:	US
Telephone Number	:	916-962-0577
Fax Number	:

Provider Business Practice Location Address
First Line	:	7916 PEBBLE BEACH DR
Second Line	:	SUITE 101
City	:	CITRUS HEIGHTS
State	:	CA
Zip	:	95610-7790
Country	:	US
Telephone Number	:	916-962-0577
Fax Number	:

Authorized Official
Title or Position	:	OWNER DENTIST
Name	:	CYNTHIA L. WEIDEMAN
Credential	:	D.D.S.
Telephone Number	:	916-962-0577

Provider Enumeration Date	:	08/13/2006
Last Update Date	:	08/22/2020

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Practice Location Address:

7916 PEBBLE BEACH DR , SUITE 101
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1255343414 — DR. KELVIN A. TSE D.D.S.
Practice Location Address:

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1992855936 — DR. WILLIAM H SWEARINGEN DDS
Practice Location Address:

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1801916986 — ELAHEH SAMSANI DDS
Practice Location Address:

7916 PEBBLE BEACH DR STE 104
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Practice Phone: 916-962-0545
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