MEDICARE: IMELDA P NAGTALON DDS., CORP.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	34370	CA
2	1223G0001X	General Practice Dentistry	49154	CA

General Provider Information

NPI Number	:	1013437094
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IMELDA P NAGTALON DDS., CORP.

Provider Business Mailing Address
First Line	:	1175 E JULIAN ST STE 4
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95116-1091
Country	:	US
Telephone Number	:	408-993-8491
Fax Number	:

Provider Business Practice Location Address
First Line	:	1175 E JULIAN ST STE 4
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95116-1091
Country	:	US
Telephone Number	:	408-993-8491
Fax Number	:	408-899-2070

Authorized Official
Title or Position	:	OWNER
Name	:	DR. IMELDA P NAGTALON
Credential	:	DDS
Telephone Number	:	408-993-8491

Provider Enumeration Date	:	06/21/2017
Last Update Date	:	07/21/2022

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