Provider Demographics
NPI:1326179631
Name:FAMILY DENTAL PRACTICE OF ROSEVILLE
Entity type:Organization
Organization Name:FAMILY DENTAL PRACTICE OF ROSEVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:D
Authorized Official - Last Name:PHIPPS
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:916-773-4343
Mailing Address - Street 1:4014 FOOTHILLS BLVD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7233
Mailing Address - Country:US
Mailing Address - Phone:916-773-4343
Mailing Address - Fax:916-773-4348
Practice Address - Street 1:4014 FOOTHILLS BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95747-7233
Practice Address - Country:US
Practice Address - Phone:916-773-4343
Practice Address - Fax:916-773-4348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA297861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty