Healthcare Provider Details

I. General information

NPI: 1528412228
Provider Name (Legal Business Name): EDINSON CAPOTE RDA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2016
Last Update Date: 04/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22283 S GARDEN AVE APT 9
HAYWARD CA
94541-6043
US

IV. Provider business mailing address

22283 S GARDEN AVE APT 9
HAYWARD CA
94541-6043
US

V. Phone/Fax

Practice location:
  • Phone: 510-269-0427
  • Fax:
Mailing address:
  • Phone: 510-269-0427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number80983
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: