Healthcare Provider Details

I. General information

NPI: 1992600027
Provider Name (Legal Business Name): ANGELO CACCIATORE DMD, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/09/2026
Last Update Date: 10/09/2026
Certification Date: 10/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12778 RANCHO PENASQUITOS BLVD STE A
SAN DIEGO CA
92129-2947
US

IV. Provider business mailing address

PO BOX 483
SAN LUIS REY CA
92068-0483
US

V. Phone/Fax

Practice location:
  • Phone: 917-468-5582
  • Fax:
Mailing address:
  • Phone: 917-468-5582
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License Number
License Number StateNULL

VIII. Authorized Official

Name: ANGELO CACCIATORE
Title or Position: CEO
Credential: DMD
Phone: 917-468-5582