Healthcare Provider Details

I. General information

NPI: 1669480992
Provider Name (Legal Business Name): MARY ANN V SANVICTORES DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 PALM AVENUE SUITE 116
IMPERIAL BEACH CA
91932-1245
US

IV. Provider business mailing address

600 PALM AVENUE SUITE 116
IMPERIAL BEACH CA
91932-1245
US

V. Phone/Fax

Practice location:
  • Phone: 619-628-8123
  • Fax: 619-628-8081
Mailing address:
  • Phone: 619-628-8123
  • Fax: 619-628-8081

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number44360
License Number StateCA

VIII. Authorized Official

Name: MRS. MARY ANN VERGARA SANVICTORES
Title or Position: DENTIST CEO
Credential: DDS
Phone: 619-628-8123