Provider Demographics
NPI:1235321852
Name:CAPITOL PERIODONTAL GROUP
Entity Type:Organization
Organization Name:CAPITOL PERIODONTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DILWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-394-6555
Mailing Address - Street 1:PO BOX 255727
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95865-5727
Mailing Address - Country:US
Mailing Address - Phone:916-394-6555
Mailing Address - Fax:916-394-6545
Practice Address - Street 1:2428 PROFESSIONAL DR
Practice Address - Street 2:STE 100
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-7774
Practice Address - Country:US
Practice Address - Phone:916-786-6585
Practice Address - Fax:916-786-7542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-16
Last Update Date:2007-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty