Healthcare Provider Details

I. General information

NPI: 1750747234
Provider Name (Legal Business Name): VILLACIS DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/13/2016
Last Update Date: 05/11/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 E CARSON PLAZA CT STE 101
CARSON CA
90746-3289
US

IV. Provider business mailing address

520 E. CARSON PLAZA CURT STE 101
CARSON CA
90746-3844
US

V. Phone/Fax

Practice location:
  • Phone: 310-313-5150
  • Fax: 310-313-5154
Mailing address:
  • Phone: 310-313-5150
  • Fax: 310-313-5154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number41690
License Number StateCA

VIII. Authorized Official

Name: DR. SASKIA M VILLACIS
Title or Position: DDS
Credential:
Phone: 310-313-5150