=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851019509
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MARIO J CORDERO-PANGRAZIO, DMD, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/18/2022
-----------------------------------------------------
Last Update Date | 08/18/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5595 WINFIELD BLVD STE 210
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95123-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 140-822-4133
-----------------------------------------------------
Fax | 408-224-4192
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5595 WINFIELD BLVD STE 210
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95123-1220
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 140-822-4133
-----------------------------------------------------
Fax | 408-224-4192
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DENTIST
-----------------------------------------------------
Name | DR. MARIO J CORDERO-PANGRAZIO
-----------------------------------------------------
Credential | DMD
-----------------------------------------------------
Telephone | 408-224-1333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QD0000X
-----------------------------------------------------
Taxonomy Name | Dental Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------