Healthcare Provider Details

I. General information

NPI: 1750023743
Provider Name (Legal Business Name): ALYSSA GIANELLA COULTER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2022
Last Update Date: 11/21/2024
Certification Date: 11/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 S EL CAMINO REAL STE 408
SAN MATEO CA
94402-3067
US

IV. Provider business mailing address

352 PINE ST
MILLBRAE CA
94030-2019
US

V. Phone/Fax

Practice location:
  • Phone: 650-212-3500
  • Fax: 650-212-3505
Mailing address:
  • Phone: 650-274-3328
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number109406
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: