Provider Demographics
NPI:1770052631
Name:AZOUZ DENTAL PRACTICE OF SACRAMENTO INC
Entity type:Organization
Organization Name:AZOUZ DENTAL PRACTICE OF SACRAMENTO INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER AND DENTIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:TODD
Authorized Official - Last Name:AZOUZ
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-708-2363
Mailing Address - Street 1:5414 SUNRISE BLVD STE D
Mailing Address - Street 2:
Mailing Address - City:CITRUS HEIGHTS
Mailing Address - State:CA
Mailing Address - Zip Code:95610-7803
Mailing Address - Country:US
Mailing Address - Phone:916-961-3383
Mailing Address - Fax:
Practice Address - Street 1:5414 SUNRISE BLVD STE D
Practice Address - Street 2:
Practice Address - City:CITRUS HEIGHTS
Practice Address - State:CA
Practice Address - Zip Code:95610-7803
Practice Address - Country:US
Practice Address - Phone:916-961-3383
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-20
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1093883464Medicaid