1063841096 NPI number — SERGIO VICUNA DENTAL CORPORATION

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063841096 NPI number — SERGIO VICUNA DENTAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SERGIO VICUNA DENTAL CORPORATION
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DAVIS SMILES DENTISTRY DENTAL GROUP
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1063841096
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17000 RED HILL AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
IRVINE
Provider Business Mailing Address State Name:
ORANGE
Provider Business Mailing Address Postal Code:
92614
Provider Business Mailing Address Country Code:
UM
Provider Business Mailing Address Telephone Number:
714-845-8890
Provider Business Mailing Address Fax Number:
949-474-1495

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4515 FERMI PLACE SUITE 106
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DAVIS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
95618
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
310-451-5060
Provider Business Practice Location Address Fax Number:
310-451-5062
Provider Enumeration Date:
11/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
VICUNA
Authorized Official First Name:
SERGIO
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER DOCTOR
Authorized Official Telephone Number:
310-451-5060

Provider Taxonomy Codes

  • Taxonomy code: 122300000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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