Provider Demographics
NPI:1225046402
Name:WOODSON, DANIEL KEITH (DDS)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:KEITH
Last Name:WOODSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1098
Mailing Address - Street 2:
Mailing Address - City:FORESTHILL
Mailing Address - State:CA
Mailing Address - Zip Code:95631-1098
Mailing Address - Country:US
Mailing Address - Phone:530-367-2250
Mailing Address - Fax:530-367-4735
Practice Address - Street 1:24400 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORESTHILL
Practice Address - State:CA
Practice Address - Zip Code:95631
Practice Address - Country:US
Practice Address - Phone:530-367-2250
Practice Address - Fax:530-367-4735
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA234171223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB23417-01Medicaid