=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407253073
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILFREDO L SANCIANCO DMD INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2014
-----------------------------------------------------
Last Update Date | 11/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3411 W SHORE RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02886-7561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-737-7716
-----------------------------------------------------
Fax | 401-737-7713
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3411 W SHORE RD
-----------------------------------------------------
City | WARWICK
-----------------------------------------------------
State | RI
-----------------------------------------------------
Zip | 02886-7561
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 401-737-7716
-----------------------------------------------------
Fax | 401-737-7713
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST/PROVIDER
-----------------------------------------------------
Name | DR. WILFREDO L. SANCIANCO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 401-737-7716
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 02633
-----------------------------------------------------
License Number State | RI
-----------------------------------------------------