Healthcare Provider Details

I. General information

NPI: 1538902416
Provider Name (Legal Business Name): JOHNNY CAPULENO DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHNNY CAPULENO DDS

II. Dates (important events)

Enumeration Date: 06/17/2024
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

517 N MAIN ST STE 300
SANTA ANA CA
92701-6703
US

IV. Provider business mailing address

517 N MAIN ST STE 300
SANTA ANA CA
92701-6703
US

V. Phone/Fax

Practice location:
  • Phone: 714-564-0510
  • Fax: 714-550-7173
Mailing address:
  • Phone: 714-564-0510
  • Fax: 714-550-7173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number109901
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number109901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: