Healthcare Provider Details

I. General information

NPI: 1548377922
Provider Name (Legal Business Name): RIAO-LUQUE DENTAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3532 20TH ST
SAN FRANCISCO CA
94110-2419
US

IV. Provider business mailing address

3532 20TH ST
SAN FRANCISCO CA
94110-2419
US

V. Phone/Fax

Practice location:
  • Phone: 415-573-5182
  • Fax: 415-643-6424
Mailing address:
  • Phone: 415-573-5182
  • Fax: 415-643-6424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number48321
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number48321
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number51643
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number51643
License Number StateCA

VIII. Authorized Official

Name: MR. CAMILO RIAO
Title or Position: OWNER
Credential: D.D.S
Phone: 415-573-5182