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Provider Information for 1124266788

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1124266788

Calendar   Last Updated:  2009-11-20
  Certification Date: 


Name Value
NPI 1124266788
Enumeration Date 2009-02-04
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address 4145 PORTOLA DR. APT. #202
SANTA CRUZ, CA 95062-4505
United States

Phone: 831-600-8081 | Fax:
View Map External Link
Primary Practice Address 9520 SOQUEL DR
APTOS, CA 95003-4160
United States

Phone: 831-688-1006 | Fax:
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
MEDICAID CA 1295810174
Primary Taxonomy Selected Taxonomy State License Number
Yes 122300000X - Dentist CA 56685