MEDICARE: MICHAEL LUKE VISTA 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	54444	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	54444	OTHER	CA	DENTAL LICENSE NUMBER

General Provider Information

NPI Number	:	1902008568
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL LUKE VISTA D.D.S.

Provider Business Mailing Address
First Line	:	1950 SPYGLASS DR
Second Line	:
City	:	SAN BRUNO
State	:	CA
Zip	:	94066-1048
Country	:	US
Telephone Number	:	650-355-7230
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	:	415-333-3400

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

Provider Enumeration Date	:	06/04/2007
Last Update Date	:	07/08/2007

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