Healthcare Provider Details

I. General information

NPI: 1619176252
Provider Name (Legal Business Name): GRACIA CUA DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 03/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2171 JUNIPERO SERRA BLVD, SUITE 110
DALY CITY CA
94014
US

IV. Provider business mailing address

2171 JUNIPERO SERRA BLVD STE 110
DALY CITY CA
94014-1987
US

V. Phone/Fax

Practice location:
  • Phone: 650-991-2288
  • Fax:
Mailing address:
  • Phone: 650-991-2288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number38787
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: