Healthcare Provider Details

I. General information

NPI: 1316148034
Provider Name (Legal Business Name): ANTONIO CUCALON III D.D.S., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2060 UNION ST SUITE 2
SAN FRANCISCO CA
94123-4101
US

IV. Provider business mailing address

2060 UNION ST SUITE 2
SAN FRANCISCO CA
94123-4101
US

V. Phone/Fax

Practice location:
  • Phone: 415-563-2348
  • Fax: 415-563-6434
Mailing address:
  • Phone: 415-563-2348
  • Fax: 415-563-6434

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number30755
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: