Provider Demographics
NPI:1285774109
Name:UC DAVIS UNIV DENTAL ASSOCIATES
Entity type:Organization
Organization Name:UC DAVIS UNIV DENTAL ASSOCIATES
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DENTAL ASSISTANT
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARYT
Authorized Official - Middle Name:
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:RDA
Authorized Official - Phone:916-734-5408
Mailing Address - Street 1:PO BOX 60000
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94160-0001
Mailing Address - Country:US
Mailing Address - Phone:916-734-5408
Mailing Address - Fax:916-734-4960
Practice Address - Street 1:2521 STOCKTON BLVD
Practice Address - Street 2:ROOM 5200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2207
Practice Address - Country:US
Practice Address - Phone:916-734-5408
Practice Address - Fax:916-734-4960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG01073-01Medicaid