MEDICARE: INSTITUTE OF ESTHETIC DENTISTRY, INC.

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	261QD0000X	Dental Clinic/Center	38843	CA

General Provider Information

NPI Number	:	1801093208
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INSTITUTE OF ESTHETIC DENTISTRY, INC.

Provider Business Mailing Address
First Line	:	4944 WINDPLAY DR
Second Line	:	SUITE 300
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-9688
Country	:	US
Telephone Number	:	916-941-2333
Fax Number	:

Provider Business Practice Location Address
First Line	:	4944 WINDPLAY DR
Second Line	:	SUITE 300
City	:	EL DORADO HILLS
State	:	CA
Zip	:	95762-9688
Country	:	US
Telephone Number	:	916-941-2333
Fax Number	:

Authorized Official
Title or Position	:	CHIEF EXECUTIVE OFFICER
Name	:	DR. GENE ALAN GOWDEY
Credential	:	DDS, MA
Telephone Number	:	916-941-2333

Provider Enumeration Date	:	06/28/2007
Last Update Date	:	08/22/2020

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