MEDICARE: NAZARETH PLAZA DENTAL GROUP

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	122300000X	Dentist	40848	CA

General Provider Information

NPI Number	:	1417385006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NAZARETH PLAZA DENTAL GROUP

Provider Business Mailing Address
First Line	:	800 S B ST STE 200
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94401-4273
Country	:	US
Telephone Number	:	650-343-0884
Fax Number	:

Provider Business Practice Location Address
First Line	:	800 S B ST STE 200
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94401-4273
Country	:	US
Telephone Number	:	650-343-0884
Fax Number	:	650-375-0231

Authorized Official
Title or Position	:	DENTIST/OWNER
Name	:	DR. LERIDA FELIZARDO LIPUMANO-PICAZO
Credential	:	D.M.D.
Telephone Number	:	650-343-0884

Provider Enumeration Date	:	10/17/2013
Last Update Date	:	10/17/2013

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