Provider Demographics
NPI:1720133796
Name:PARKSIDE DENTAL CARE
Entity Type:Organization
Organization Name:PARKSIDE DENTAL CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:AVRIL
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:ALTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:707-427-2222
Mailing Address - Street 1:1325 TRAVIS BLVD
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-4611
Mailing Address - Country:US
Mailing Address - Phone:707-427-2222
Mailing Address - Fax:707-427-0562
Practice Address - Street 1:1325 TRAVIS BLVD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-4611
Practice Address - Country:US
Practice Address - Phone:707-427-2222
Practice Address - Fax:707-427-0562
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA487101223E0200X
CA284791223G0001X
CA279641223G0001X
CA301171223G0001X
CA516771223G0001X
CA494431223P0300X
CA193001223S0112X
CA455801223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
Not Answered1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Not Answered1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty
Not Answered1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Not Answered1223X0400XDental ProvidersDentistOrthodontics and Dentofacial OrthopedicsGroup - Multi-Specialty