| NPI | 1558668244 |
|---|---|
| Entity Type | Organization |
| Authorized Contact | TIMOTHY MICKIEWICZ Dentist 916-457-7710 |
| Organization Subpart ? | No |
| Primary Taxonomy | 305R00000X Preferred Provider Organization (Licence: CA 30810) |
| Enumeration Date | 2011-02-16 |
| Last Update Date | 2014-08-13 |