Basic Information
| Provider Information | |||||||||
| NPI: | 1386114981 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GUILLORY | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | MARIA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDH | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 140 STONY POINT RD STE A | ||||||||
| Address2: | |||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 954014121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075783118 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 140 STONY POINT ROAD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SANTA ROSA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7075783118 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/27/2018 | ||||||||
| LastUpdateDate: | 11/27/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 124Q00000X | 19668 | CA | Y | Dental Providers | Dental Hygienist |
ID Information
| ID | Type | State | Issuer | Description | RDA19668 | 01 | CA | DCA | OTHER |