=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255732046
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DEANNA RISOS DMD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2014
-----------------------------------------------------
Last Update Date | 09/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 841 KUHN DR STE 102
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91914-4523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-482-8880
-----------------------------------------------------
Fax | 619-482-0099
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 841 KUHN DR STE 102
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91914-4523
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-482-8880
-----------------------------------------------------
Fax | 619-482-0099
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER/DOCTOR
-----------------------------------------------------
Name | DR. DEANNA B RISOS
-----------------------------------------------------
Credential | D.M.D.
-----------------------------------------------------
Telephone | 619-482-8880
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 50416
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------