Provider Demographics
NPI:1679728398
Name:ZINFANDEL DENTAL PRACTICE
Entity Type:Organization
Organization Name:ZINFANDEL DENTAL PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:916-391-1156
Mailing Address - Street 1:6829 SAVINGS PL STE 101
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95828-1291
Mailing Address - Country:US
Mailing Address - Phone:916-391-1156
Mailing Address - Fax:
Practice Address - Street 1:6829 SAVINGS PL STE 101
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95828-1291
Practice Address - Country:US
Practice Address - Phone:916-391-1156
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-21
Last Update Date:2008-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA50333122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG93130-01OtherDENTI-CAL BILLING NUMBER