Healthcare Provider Details

I. General information

NPI: 1770182529
Provider Name (Legal Business Name): VIRGINIA SANTIAGO WILLIAMS PROPHY TECH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/22/2020
Last Update Date: 10/22/2020
Certification Date: 10/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 AREA DENTAL CLINIC BLDG 210735 C ST
CAMP PENDLETON CA
92055-5221
US

IV. Provider business mailing address

PO BOX 555221
CAMP PENDLETON CA
92055-5221
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-2569
  • Fax:
Mailing address:
  • Phone: 760-725-2569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: