MEDICARE: DR. FIDELIS SANTILLAN KING D.D.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	36423	CA

General Provider Information

NPI Number	:	1265594428
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FIDELIS SANTILLAN KING D.D.S.

Provider Business Mailing Address
First Line	:	19139 STARE ST
Second Line	:
City	:	NORTHRIDGE
State	:	CA
Zip	:	91324-1266
Country	:	US
Telephone Number	:	323-464-8677
Fax Number	:	323-463-4692

Provider Business Practice Location Address
First Line	:	646 N LARCHMONT BLVD
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90004-1308
Country	:	US
Telephone Number	:	323-464-8677
Fax Number	:	323-463-4692

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/14/2006
Last Update Date	:	07/08/2007

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