Healthcare Provider Details

I. General information

NPI: 1568000743
Provider Name (Legal Business Name): MARIA ANGELICA FONSECA RICAURTE DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. MARIA ANGELICA VENKATA

II. Dates (important events)

Enumeration Date: 12/18/2019
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2999 REGENT ST STE 714
BERKELEY CA
94705-2122
US

IV. Provider business mailing address

3700 CASA VERDE ST APT 2504
SAN JOSE CA
95134-3338
US

V. Phone/Fax

Practice location:
  • Phone: 510-848-3143
  • Fax:
Mailing address:
  • Phone: 310-905-0335
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0700X
TaxonomyProsthodontics
License NumberDDS104383
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: