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General NPI Number Information
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NPI Number | 1487969028
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Entity Type | Organization
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Legal Business Name | SYCAMORE FAMILY DENTISTRY
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Dates
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Enumeration Date | 08/06/2010
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Last Update Date | 08/06/2010
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Provider Practice Location Address
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Address Line | 1581 SYCAMORE AVE SUITE 3
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City | HERCULES
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State | CA
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Zip | 94547-1700
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Country | US
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Telephone | 510-799-2900
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Fax | 510-799-2902
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Provider Business Mailing Address
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Address Line | 1581 SYCAMORE AVE SUITE 3
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City | HERCULES
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State | CA
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Zip | 94547-1700
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Country | US
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Telephone | 510-799-2900
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Fax | 510-799-2902
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. ELMER SANTOS DE LEON
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Credential | DDS
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Telephone | 510-799-2900
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1223G0001X
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Taxonomy Name | General Practice Dentistry
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License Number | 55619
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License Number State | CA
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