Healthcare Provider Details

I. General information

NPI: 1205712494
Provider Name (Legal Business Name): DANIEL ULLOA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2025
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6165 VALLEY SPRINGS PKWY STE E
RIVERSIDE CA
92507-0955
US

IV. Provider business mailing address

10 THUNDER RUN APT 22E
IRVINE CA
92614-7027
US

V. Phone/Fax

Practice location:
  • Phone: 951-214-6585
  • Fax: 951-214-6589
Mailing address:
  • Phone: 714-351-3351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number112039
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: