Healthcare Provider Details

I. General information

NPI: 1629484985
Provider Name (Legal Business Name): DANIEL HULME
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2014
Last Update Date: 02/24/2021
Certification Date: 02/24/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1773 DOMINICAN WAY
SANTA CRUZ CA
95065-1526
US

IV. Provider business mailing address

5010 LAGUNA BLVD STE 101
ELK GROVE CA
95758-4148
US

V. Phone/Fax

Practice location:
  • Phone: 831-475-5500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number63334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: