=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053775064
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SAMANTHA AGUINALDO-WETTERHOLM D.D.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2016
-----------------------------------------------------
Last Update Date | 04/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3050 E 16TH ST
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94601-2319
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-535-4711
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2208 LINCOLN AVE APT B
-----------------------------------------------------
City | ALAMEDA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94501-2928
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-618-0969
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 65360
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------