Provider Demographics
NPI:1639492226
Name:SIERRA PERIODONTAL GROUP
Entity Type:Organization
Organization Name:SIERRA PERIODONTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:S
Authorized Official - Last Name:CORBITT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-962-0545
Mailing Address - Street 1:7916 PEBBLE BEACH DR STE 104
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-7790
Mailing Address - Country:US
Mailing Address - Phone:916-962-0545
Mailing Address - Fax:916-962-0927
Practice Address - Street 1:7916 PEBBLE BEACH DR STE 104
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7790
Practice Address - Country:US
Practice Address - Phone:916-962-0545
Practice Address - Fax:916-962-0927
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-10
Last Update Date:2010-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA474151223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty