Provider Demographics
NPI:1013052836
Name:SERAFICA DENTAL CORPORATION
Entity Type:Organization
Organization Name:SERAFICA DENTAL CORPORATION
Other - Org Name:LAKEWOOD DENTAL
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:DENTIST OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:PRONSTROLLER
Authorized Official - Last Name:SERAFICA
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:707-836-8685
Mailing Address - Street 1:9046 BROOKS RD S
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7811
Mailing Address - Country:US
Mailing Address - Phone:707-836-8685
Mailing Address - Fax:707-836-8631
Practice Address - Street 1:9046 BROOKS RD S
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:CA
Practice Address - Zip Code:95492-7811
Practice Address - Country:US
Practice Address - Phone:707-836-8685
Practice Address - Fax:707-836-8631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA481801223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB-48180-01OtherHEALTHY FAMILIES
CAG-93771-01Medicaid