Healthcare Provider Details

I. General information

NPI: 1497382733
Provider Name (Legal Business Name): DENISE EBALO VILLANUEVA DDS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/26/2020
Last Update Date: 09/09/2021
Certification Date: 09/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

995 MONTAGUE EXPY STE 210
MILPITAS CA
95035-6885
US

IV. Provider business mailing address

1828 SADDLE PARK AVE
SAN JOSE CA
95138-2768
US

V. Phone/Fax

Practice location:
  • Phone: 408-946-5858
  • Fax:
Mailing address:
  • Phone: 408-688-6375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number106937
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: