Provider Demographics
NPI:1649562182
Name:CITRUS HEIGHTS DENTAL
Entity Type:Organization
Organization Name:CITRUS HEIGHTS DENTAL
Other - Org Name:CITRUS HEIGHTS DENTAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:INNA
Authorized Official - Middle Name:
Authorized Official - Last Name:SHTURMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-723-8900
Mailing Address - Street 1:6994 SUNRISE BLVD
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-3144
Mailing Address - Country:US
Mailing Address - Phone:916-723-8900
Mailing Address - Fax:916-723-5168
Practice Address - Street 1:6994 SUNRISE BLVD
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-3144
Practice Address - Country:US
Practice Address - Phone:916-723-8900
Practice Address - Fax:916-723-5168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA45975Medicaid