Provider Demographics
NPI:1619758091
Name:NORTHSTATE DENTAL
Entity Type:Organization
Organization Name:NORTHSTATE DENTAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHEUNG
Authorized Official - Suffix:
Authorized Official - Credentials:PHARMD
Authorized Official - Phone:916-216-6202
Mailing Address - Street 1:9700 W TARON DRIVE
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757
Mailing Address - Country:US
Mailing Address - Phone:916-686-7300
Mailing Address - Fax:
Practice Address - Street 1:2400 MARITIME DRIVE
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758
Practice Address - Country:US
Practice Address - Phone:916-686-8914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-11
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty