Basic Information
| Provider Information | |||||||||
| NPI: | 1700060514 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF SAN JOAQUIN | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1020 | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952013120 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686600 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W HOSPITAL RD | ||||||||
| Address2: | |||||||||
| City: | FRENCH CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952319693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2094686600 | ||||||||
| FaxNumber: | 2094687042 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2007 | ||||||||
| LastUpdateDate: | 08/24/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KAPRE | ||||||||
| AuthorizedOfficialFirstName: | SHEELA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2094686600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SAN JOAQUIN GENERAL HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD, FCCP, FACP | ||||||||
| NPICertificationDate: | 08/24/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 030000087 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | G01021-01 | 01 | CA | DENTI-CAL | OTHER |