Provider Demographics
NPI:1790711372
Name:SALKOLA, MIMI (DDS)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:
Last Name:SALKOLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:555 W BENJAMIN HOLT DR
Mailing Address - Street 2:BUILDING B
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-3839
Mailing Address - Country:US
Mailing Address - Phone:209-476-4700
Mailing Address - Fax:209-478-6890
Practice Address - Street 1:3920 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-4733
Practice Address - Country:US
Practice Address - Phone:650-813-6166
Practice Address - Fax:650-813-6166
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2009-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA456121223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice