Provider Demographics
NPI:1669114898
Name:FOULADI PROFESSIONAL DENTAL CORP.
Entity type:Organization
Organization Name:FOULADI PROFESSIONAL DENTAL CORP.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CELIA
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:217-540-2100
Mailing Address - Street 1:7551 TIMBERLAKE WAY STE 120
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95823-5421
Mailing Address - Country:US
Mailing Address - Phone:916-423-4092
Mailing Address - Fax:916-423-3125
Practice Address - Street 1:7551 TIMBERLAKE WAY STE 120
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95823-5421
Practice Address - Country:US
Practice Address - Phone:916-423-4092
Practice Address - Fax:916-423-3125
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOULADI PROFESSIONAL DENTAL CORP.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-08
Last Update Date:2022-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty