Provider Demographics
NPI:1265606487
Name:FOLSOM DENTAL GROUP
Entity type:Organization
Organization Name:FOLSOM DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:STEVE
Authorized Official - Middle Name:
Authorized Official - Last Name:SAMUSENKO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-351-9808
Mailing Address - Street 1:1840 PRAIRIE CITY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-9579
Mailing Address - Country:US
Mailing Address - Phone:916-351-9808
Mailing Address - Fax:916-351-9847
Practice Address - Street 1:1840 PRAIRIE CITY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-9579
Practice Address - Country:US
Practice Address - Phone:916-351-9808
Practice Address - Fax:916-351-9847
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-18
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA416891223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty