Provider Demographics
NPI:1710351192
Name:CAPITOL ORAL-SYSTEMIC HEALTH INC
Entity Type:Organization
Organization Name:CAPITOL ORAL-SYSTEMIC HEALTH INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:C
Authorized Official - Last Name:VERNON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-442-4674
Mailing Address - Street 1:2131 CAPITOL AVE
Mailing Address - Street 2:300
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5755
Mailing Address - Country:US
Mailing Address - Phone:916-813-3743
Mailing Address - Fax:916-446-6636
Practice Address - Street 1:2131 CAPITOL AVE
Practice Address - Street 2:300
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5755
Practice Address - Country:US
Practice Address - Phone:916-813-3743
Practice Address - Fax:916-446-6636
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-22
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA26934122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7491110001Medicare NSC