Provider Demographics
NPI:1780825968
Name:GEDESTAD, DOUGLAS ALAN (DMD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ALAN
Last Name:GEDESTAD
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2409 L ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95816-5025
Mailing Address - Country:US
Mailing Address - Phone:916-448-1444
Mailing Address - Fax:916-447-2125
Practice Address - Street 1:2409 L ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816-5025
Practice Address - Country:US
Practice Address - Phone:916-448-1444
Practice Address - Fax:916-447-2125
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-17
Last Update Date:2009-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28555122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist