=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770569600
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN P DIPONZIANO DDS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2005
-----------------------------------------------------
Last Update Date | 04/18/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 680 BANCROFT AVE
-----------------------------------------------------
City | SAN LEANDRO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94577-2904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-569-0218
-----------------------------------------------------
Fax | 510-569-9714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2346
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-0346
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-569-0218
-----------------------------------------------------
Fax | 510-569-9714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 122300000X
-----------------------------------------------------
Taxonomy Name | Dentist
-----------------------------------------------------
License Number | 55315
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------