Provider Demographics
NPI:1679647762
Name:SCEVILLE DENTAL GROUP
Entity type:Organization
Organization Name:SCEVILLE DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFERY
Authorized Official - Middle Name:
Authorized Official - Last Name:SCEVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-847-8091
Mailing Address - Street 1:1390 W H ST STE D
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-3529
Mailing Address - Country:US
Mailing Address - Phone:209-847-8091
Mailing Address - Fax:209-847-3314
Practice Address - Street 1:1390 W H ST
Practice Address - Street 2:SUITE D-1
Practice Address - City:OAKDALE
Practice Address - State:CA
Practice Address - Zip Code:95361-3570
Practice Address - Country:US
Practice Address - Phone:209-847-8091
Practice Address - Fax:209-847-3314
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-20
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51300122300000X
CA46428122300000X
332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty