Healthcare Provider Details

I. General information

NPI: 1285788976
Provider Name (Legal Business Name): PETER D. CANCELLIER D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PETER DANIELE CANCELLIER D.D.S.

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 07/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 CREEK RD. #330
IRVINE CA
92604-7705
US

IV. Provider business mailing address

33 CREEK RD. #330
IRVINE CA
92604-7705
US

V. Phone/Fax

Practice location:
  • Phone: 949-857-3636
  • Fax:
Mailing address:
  • Phone: 949-857-3636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number30764
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: