=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477929313
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | C-DENTAL X-RAY, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2015
-----------------------------------------------------
Last Update Date | 08/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3535 ROSS AVE BLDG II STE. 208
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95124-3054
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-264-2220
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 450 SUTTER ST STE. 1542
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94108-4206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-421-1389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. JEROME N PECK
-----------------------------------------------------
Credential | DLXT
-----------------------------------------------------
Telephone | 650-207-6209
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 292200000X
-----------------------------------------------------
Taxonomy Name | Dental Laboratory
-----------------------------------------------------
License Number | RHP00053519
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------