Healthcare Provider Details

I. General information

NPI: 1689872194
Provider Name (Legal Business Name): JOSE E URRESTI SOBERON D.D.S
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2007
Last Update Date: 09/25/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1470 PANTOPS MOUNTAIN PL
CHARLOTTESVILLE VA
22911-4600
US

IV. Provider business mailing address

1615 OLD TRAIL DR
CROZET VA
22932-3342
US

V. Phone/Fax

Practice location:
  • Phone: 434-817-1817
  • Fax: 434-817-1819
Mailing address:
  • Phone: 434-282-5469
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number10258
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number0401413819
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: