Healthcare Provider Details

I. General information

NPI: 1124761333
Provider Name (Legal Business Name): ROWENA LAGLEVA ROMERO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2022
Last Update Date: 04/15/2022
Certification Date: 04/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 HICKEY BLVD
PACIFICA CA
94044-1214
US

IV. Provider business mailing address

1102 E 16TH AVE
SAN MATEO CA
94402-2139
US

V. Phone/Fax

Practice location:
  • Phone: 650-359-7720
  • Fax: 650-359-7785
Mailing address:
  • Phone: 650-787-8976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROWENA LAGLEVA ROMERO
Title or Position: DDS
Credential:
Phone: 650-787-8976