Healthcare Provider Details

I. General information

NPI: 1992195119
Provider Name (Legal Business Name): KOA AND VALLARTA DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2015
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1474 N MILPITAS BLVD
MILPITAS CA
95035-3118
US

IV. Provider business mailing address

1474 N MILPITAS BLVD
MILPITAS CA
95035-3118
US

V. Phone/Fax

Practice location:
  • Phone: 408-946-1397
  • Fax: 408-262-1337
Mailing address:
  • Phone: 408-946-1397
  • Fax: 408-262-1337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number56838
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL VALLARTA
Title or Position: DENTIST/OWNER
Credential: DMD
Phone: 408-946-1397