Healthcare Provider Details

I. General information

NPI: 1205006707
Provider Name (Legal Business Name): MARY BOOTS FIESTA ROBINOS DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 03/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2664 BERRYESSA RD SUITE 213
SAN JOSE CA
95132-2925
US

IV. Provider business mailing address

5424 PORT SAILWOOD DR
NEWARK CA
94560-2670
US

V. Phone/Fax

Practice location:
  • Phone: 510-364-9619
  • Fax:
Mailing address:
  • Phone: 510-364-9619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number56805
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: