=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073349932
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SONRISAS DENTAL HEALTH, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2024
-----------------------------------------------------
Last Update Date | 09/09/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1740 MARCO POLO WAY SUITE 4
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-727-3480
-----------------------------------------------------
Fax | 650-727-3519
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 430 N EL CAMINO REAL
-----------------------------------------------------
City | SAN MATEO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94401-3710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-727-3480
-----------------------------------------------------
Fax | 650-727-3519
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TRACEY CARRILLO FECHER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 650-727-3484
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223D0001X
-----------------------------------------------------
Taxonomy Name | Public Health Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------