Provider Demographics
NPI:1295062503
Name:WOODCREEK DENTISTRY INC.
Entity type:Organization
Organization Name:WOODCREEK DENTISTRY INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:KENNETH
Authorized Official - Last Name:RALLI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-773-0800
Mailing Address - Street 1:7456 FOOTHILLS BLVD.
Mailing Address - Street 2:#14
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747
Mailing Address - Country:US
Mailing Address - Phone:916-773-0800
Mailing Address - Fax:916-773-0835
Practice Address - Street 1:7456 FOOTHILLS BLVD STE 14
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-6562
Practice Address - Country:US
Practice Address - Phone:916-773-0800
Practice Address - Fax:916-773-0835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-06
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA47828122300000X
CA47783122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty