Basic Information
| Provider Information | |||||||||
| NPI: | 1639362502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KAO | ||||||||
| FirstName: | PEY-RU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | IX | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2105 KAWANA SPRINGS RD | ||||||||
| Address2: | UNIT 6105 | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954046355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004174444 | ||||||||
| FaxNumber: | 7145713560 | ||||||||
| Practice Location | |||||||||
| Address1: | 1240 FARMERS LN | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954056707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075425200 | ||||||||
| FaxNumber: | 7075793207 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2007 | ||||||||
| LastUpdateDate: | 08/23/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 55711 | CA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | D55711 | 05 | CA | MEDICAID |