MEDICARE: SONRISAS BRIGHT DENTAL 1, LP

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	261QD0000X	Dental Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1609060649	OTHER	CA	NEA

General Provider Information

NPI Number	:	1487320008
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SONRISAS BRIGHT DENTAL 1, LP

Provider Business Mailing Address
First Line	:	959 WOODSIDE RD
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94061-3644
Country	:	US
Telephone Number	:	650-361-1801
Fax Number	:	650-361-1809

Provider Business Practice Location Address
First Line	:	959 WOODSIDE RD
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94061-3644
Country	:	US
Telephone Number	:	650-361-1801
Fax Number	:	650-361-1809

Authorized Official
Title or Position	:	OWNER/DENTIST
Name	:	EDWIN CHICCHON
Credential	:	DDS
Telephone Number	:	510-713-8986

Provider Enumeration Date	:	08/23/2021
Last Update Date	:	08/23/2021

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