Provider Demographics
NPI:1730679747
Name:FOLSOM DENTAL GROUP
Entity Type:Organization
Organization Name:FOLSOM DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL DENTIST
Authorized Official - Prefix:
Authorized Official - First Name:BRAULIO
Authorized Official - Middle Name:
Authorized Official - Last Name:ULLOA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:415-400-5115
Mailing Address - Street 1:3085 24TH ST STE 202
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-4147
Mailing Address - Country:US
Mailing Address - Phone:415-525-3371
Mailing Address - Fax:
Practice Address - Street 1:3085 24TH ST STE 202
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-4147
Practice Address - Country:US
Practice Address - Phone:415-525-3371
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-15
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA476731223G0001X
CA1003111223G0001X
CA1014551223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty