MEDICARE: TAMAL VISTA FAMILY DENTISTRY

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	261QD0000X	Dental Clinic/Center

General Provider Information

NPI Number	:	1154999134
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	TAMAL VISTA FAMILY DENTISTRY

Provider Business Mailing Address
First Line	:	1447 4TH ST
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-2811
Country	:	US
Telephone Number	:	415-453-4720
Fax Number	:	415-453-4727

Provider Business Practice Location Address
First Line	:	1447 4TH ST
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94901-2811
Country	:	US
Telephone Number	:	415-453-4720
Fax Number	:	415-453-4727

Authorized Official
Title or Position	:	OWNER
Name	:	DR. DANIEL ERIC SCOTT
Credential	:	DDS
Telephone Number	:	415-453-4720

Provider Enumeration Date	:	06/15/2021
Last Update Date	:	06/15/2021

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