MEDICARE: DR. PHEONIX ELLIS SINCLAIR D.D.S.

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	D25841	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	D25841	OTHER	CA	DENTAL

General Provider Information

NPI Number	:	1952450686
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. PHEONIX ELLIS SINCLAIR D.D.S.

Provider Business Mailing Address
First Line	:	3335 ROLLS DR
Second Line	:
City	:	CAMERON PARK
State	:	CA
Zip	:	95682-9246
Country	:	US
Telephone Number	:	530-676-7197
Fax Number	:	530-676-7198

Provider Business Practice Location Address
First Line	:	4140 MOTHER LODE DR
Second Line	:	SUITE 112
City	:	SHINGLE SPRINGS
State	:	CA
Zip	:	95682-8038
Country	:	US
Telephone Number	:	530-672-8059
Fax Number	:	530-672-2111

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

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	07/09/2007

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