MEDICARE: DR. EMILIO VISEY VISTA D.M.D.

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	25335	CA

General Provider Information

NPI Number	:	1700096617
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EMILIO VISEY VISTA D.M.D.

Provider Business Mailing Address
First Line	:	4972 MISSION ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94112-3416
Country	:	US
Telephone Number	:	209-830-6613
Fax Number	:

Provider Business Practice Location Address
First Line	:	4972 MISSION ST
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94112-3416
Country	:	US
Telephone Number	:	415-333-3400
Fax Number	:

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

Provider Enumeration Date	:	05/23/2007
Last Update Date	:	08/08/2007

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