Healthcare Provider Details

I. General information

NPI: 1467105031
Provider Name (Legal Business Name): CUPERTINO DENTAL SPECIALTY GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2022
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10373 TORRE AVENUE SUITE G
CUPERTINO CA
95014-9501
US

IV. Provider business mailing address

10383 TORRE AVE STE I
CUPERTINO CA
95014-3238
US

V. Phone/Fax

Practice location:
  • Phone: 408-508-7560
  • Fax: 408-508-7530
Mailing address:
  • Phone: 408-257-3031
  • Fax: 408-508-7530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number
License Number State

VIII. Authorized Official

Name: MELINA LUCCHINI
Title or Position: SUPERVISOR
Credential:
Phone: 408-257-3031