Basic Information
| Provider Information | |||||||||
| NPI: | 1063841096 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SERGIO VICUNA DENTAL CORPORATION | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | DAVIS SMILES DENTISTRY DENTAL GROUP | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17000 RED HILL AVENUE | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | ORANGE | ||||||||
| PostalCode: | 92614 | ||||||||
| CountryCode: | UM | ||||||||
| TelephoneNumber: | 7148458890 | ||||||||
| FaxNumber: | 9494741495 | ||||||||
| Practice Location | |||||||||
| Address1: | 4515 FERMI PLACE SUITE 106 | ||||||||
| Address2: | |||||||||
| City: | DAVIS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104515060 | ||||||||
| FaxNumber: | 3104515062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/12/2013 | ||||||||
| LastUpdateDate: | 11/12/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | VICUNA | ||||||||
| AuthorizedOfficialFirstName: | SERGIO | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 3104515060 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | DDS | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 122300000X | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist |
No ID Information.