Healthcare Provider Details

I. General information

NPI: 1265858138
Provider Name (Legal Business Name): SAMUEL EN-TAO KUO D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 10/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 COMMERCIAL WAY
SANTA CRUZ CA
95065-1819
US

IV. Provider business mailing address

1830 COMMERCIAL WAY
SANTA CRUZ CA
95065-1819
US

V. Phone/Fax

Practice location:
  • Phone: 831-464-5409
  • Fax:
Mailing address:
  • Phone: 831-464-5409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number63064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: