Provider Demographics
NPI:1316944465
Name:UNIVERSITY CALIFORNIA DAVIS MEDICAL CENTER, UNIVERSITY DENTAL ASSOC
Entity type:Organization
Organization Name:UNIVERSITY CALIFORNIA DAVIS MEDICAL CENTER, UNIVERSITY DENTAL ASSOC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR DENTAL CLINIC
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:LYONS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-734-5408
Mailing Address - Street 1:2521 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2207
Mailing Address - Country:US
Mailing Address - Phone:916-734-5408
Mailing Address - Fax:916-734-1299
Practice Address - Street 1:2521 STOCKTON BLVD
Practice Address - Street 2:
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:916-734-1299
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA233611223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0700XDental ProvidersDentistProsthodonticsGroup - Multi-Specialty