MEDICARE: LOURDES CARDOSO DDS INC.

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	:	1205482536
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LOURDES CARDOSO DDS INC.

Provider Business Mailing Address
First Line	:	7270 VICTORIA PARK LN STE 3A
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-1850
Country	:	US
Telephone Number	:	909-803-8641
Fax Number	:	909-803-8643

Provider Business Practice Location Address
First Line	:	7270 VICTORIA PARK LN STE 3A
Second Line	:
City	:	RANCHO CUCAMONGA
State	:	CA
Zip	:	91739-1850
Country	:	US
Telephone Number	:	909-803-8641
Fax Number	:	909-803-8643

Authorized Official
Title or Position	:	OWNER/CEO
Name	:	LOURDES CARDOSO
Credential	:	DDS
Telephone Number	:	909-803-8641

Provider Enumeration Date	:	08/13/2019
Last Update Date	:	08/13/2019

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