Healthcare Provider Details

I. General information

NPI: 1467572834
Provider Name (Legal Business Name): CUPERTINO DENTAL ORTHO-PEDO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10393 TORRE AVE SUITE K
CUPERTINO CA
95014-3235
US

IV. Provider business mailing address

10393 TORRE AVE SUITE K
CUPERTINO CA
95014-3235
US

V. Phone/Fax

Practice location:
  • Phone: 408-996-2909
  • Fax:
Mailing address:
  • Phone: 408-996-2909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number34600
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID THEODORE CONSTANT
Title or Position: PARTNER
Credential: DDS
Phone: 408-996-2909