Healthcare Provider Details

I. General information

NPI: 1881884930
Provider Name (Legal Business Name): FILLMORE DENTAL SPA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 07/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3220 FILLMORE ST
SAN FRANCISCO CA
94123-3403
US

IV. Provider business mailing address

3220 FILLMORE ST
SAN FRANCISCO CA
94123-3403
US

V. Phone/Fax

Practice location:
  • Phone: 415-614-9850
  • Fax: 415-614-9881
Mailing address:
  • Phone: 415-614-9850
  • Fax: 415-614-9881

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number43656
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number43590
License Number StateCA

VIII. Authorized Official

Name: CECILA SANTOS-BERKOWITZ
Title or Position: OWNER
Credential: D.M.D.
Phone: 415-614-9850