1245504356 NPI number — DR. ODETTE MORENA QUINTANILLA DDS

Table of content: DR. ODETTE MORENA QUINTANILLA DDS (NPI 1245504356)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245504356 NPI number — DR. ODETTE MORENA QUINTANILLA DDS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
QUINTANILLA
Provider First Name:
ODETTE
Provider Middle Name:
MORENA
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DDS
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CASTILLO
Provider Other First Name:
ODETTE
Provider Other Middle Name:
MORENA
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
DDS
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1245504356
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
208 VINTAGE WAY
Provider Second Line Business Mailing Address:
STE K23
Provider Business Mailing Address City Name:
NOVATO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94945-5014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
415-898-5100
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 VINTAGE WAY
Provider Second Line Business Practice Location Address:
STE K23
Provider Business Practice Location Address City Name:
NOVATO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94945-5014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-898-5100
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/07/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1223G0001X , with the licence number:  47160 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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