=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154923548
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRACE LACSON DEL ROSARIO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2020
-----------------------------------------------------
Last Update Date | 11/11/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35111 NEWARK BLVD STE A
-----------------------------------------------------
City | NEWARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94560-1258
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-494-0404
-----------------------------------------------------
Fax | 510-494-1621
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 32364 DYER ST
-----------------------------------------------------
City | UNION CITY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94587-1720
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-324-2000
-----------------------------------------------------
Fax | 510-288-1394
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | DDS40644
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------