Provider Demographics
NPI:1235871450
Name:FOULADI PROFESSIONAL DENTAL CORP.
Entity Type:Organization
Organization Name:FOULADI PROFESSIONAL DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDIANTOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:1603 EUREKA RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3028
Mailing Address - Country:US
Mailing Address - Phone:916-782-6868
Mailing Address - Fax:916-782-6878
Practice Address - Street 1:1603 EUREKA RD STE 100
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-3028
Practice Address - Country:US
Practice Address - Phone:916-782-6868
Practice Address - Fax:916-782-6878
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOULADI PROFESSIONAL DENTAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty