Provider Demographics
NPI:1205129624
Name:DR.'S SHTURMAN, MICHELSON AND KISILYUK A DENTAL CORPORATION
Entity type:Organization
Organization Name:DR.'S SHTURMAN, MICHELSON AND KISILYUK A DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CAMPBELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-737-6453
Mailing Address - Street 1:1050 NORTHGATE DR
Mailing Address - Street 2:250B
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2526
Mailing Address - Country:US
Mailing Address - Phone:415-306-1456
Mailing Address - Fax:
Practice Address - Street 1:1050 NORTHGATE DR
Practice Address - Street 2:250B
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2526
Practice Address - Country:US
Practice Address - Phone:415-306-1456
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA45975122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty