=====================================================
General NPI Number Information
=====================================================
NPI Number | 1871622266
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOUIS S. D'AGOSTA, DDS, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/03/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 255 CRESTVIEW DR
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95050-6503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-248-7048
-----------------------------------------------------
Fax | 408-248-7049
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 255 CRESTVIEW DR
-----------------------------------------------------
City | SANTA CLARA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95050-6503
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-248-7048
-----------------------------------------------------
Fax | 408-248-7049
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DENTIST
-----------------------------------------------------
Name | LOUIS SALVATORE D'AGOSTA
-----------------------------------------------------
Credential | DDS
-----------------------------------------------------
Telephone | 408-248-7048
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223G0001X
-----------------------------------------------------
Taxonomy Name | General Practice Dentistry
-----------------------------------------------------
License Number | 22794
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------