=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952121048
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VIVIENE VALDEZ DENTAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2024
-----------------------------------------------------
Last Update Date | 11/07/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2595 FOLSOM ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94110-2621
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-259-9255
-----------------------------------------------------
Fax | 916-384-3844
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3075 BEACON BLVD
-----------------------------------------------------
City | WEST SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95691-3462
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-259-9255
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | VIVIENE VALDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 916-259-9255
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223P0221X
-----------------------------------------------------
Taxonomy Name | Pediatric Dentistry
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------