=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033215413
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PATRICIA PATINO DDS INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/15/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 S JUNIPER STREET
-----------------------------------------------------
City | ESCOUDIDO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 92025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-740-5979
-----------------------------------------------------
Fax | 760-740-0612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 S JUNIPER STREET
-----------------------------------------------------
City | ESCOUDIDO
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 92025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-740-5979
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MRS. STELLE PATRICIA PATINO
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 760-740-5979
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 51637
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------