Healthcare Provider Details

I. General information

NPI: 1629565338
Provider Name (Legal Business Name): ON-SITE DENTAL CARE FOUNDATION, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/18/2018
Last Update Date: 04/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 NEWBERRY DR STE 200
SAN JOSE CA
95118-1566
US

IV. Provider business mailing address

PO BOX 41111
SAN JOSE CA
95160-1111
US

V. Phone/Fax

Practice location:
  • Phone: 408-315-4864
  • Fax: 408-608-2205
Mailing address:
  • Phone: 408-315-4864
  • Fax: 408-608-2205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State

VIII. Authorized Official

Name: CHERYL MARTINE WALTER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 408-315-4864