Basic Information
| Provider Information | |||||||||
| NPI: | 1548470024 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIPASUPIL | ||||||||
| FirstName: | ROMEO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DDS | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 939 | ||||||||
| Address2: | |||||||||
| City: | ANGELS CAMP | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952220939 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2097546240 | ||||||||
| FaxNumber: | 2097546274 | ||||||||
| Practice Location | |||||||||
| Address1: | 12150 NEW YORK RANCH RD | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956429407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092572460 | ||||||||
| FaxNumber: | 2092572464 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2007 | ||||||||
| LastUpdateDate: | 08/31/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 37813 | CA | Y | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 330759641 | 01 | CA | TAX IDENTIFICATION NUMBER | OTHER |