Provider Demographics
NPI:1457362584
Name:POWELL, MYRON ROBERT (DDS)
Entity Type:Individual
Prefix:DR
First Name:MYRON
Middle Name:ROBERT
Last Name:POWELL
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8883 SHELDON OAKS LANE
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624
Mailing Address - Country:US
Mailing Address - Phone:916-682-5445
Mailing Address - Fax:916-422-2459
Practice Address - Street 1:4500 47TH AVE
Practice Address - Street 2:STE 1
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95824
Practice Address - Country:US
Practice Address - Phone:916-422-1917
Practice Address - Fax:916-422-2459
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA259691223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice