Provider Demographics
NPI:1962735993
Name:CAPITOL PERIODONTAL GROUP
Entity type:Organization
Organization Name:CAPITOL PERIODONTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INSURANCE SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:RENEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-691-1050
Mailing Address - Street 1:9309 OFFICE PARK CIR STE 120
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-8072
Mailing Address - Country:US
Mailing Address - Phone:916-691-1050
Mailing Address - Fax:916-691-1066
Practice Address - Street 1:2535 E BIDWELL ST STE 150
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-6458
Practice Address - Country:US
Practice Address - Phone:916-984-1109
Practice Address - Fax:916-984-1764
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-09
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA226397441223P0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty