MEDICARE: DR. RICHARD FUENTES DDS

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	B-23184	CA

General Provider Information

NPI Number	:	1245362102
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RICHARD FUENTES DDS

Provider Business Mailing Address
First Line	:	1928 HUNTINGTON DR
Second Line	:	SUITE #A
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-4874
Country	:	US
Telephone Number	:	626-441-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	1928 HUNTINGTON DR
Second Line	:	SUITE #A
City	:	SOUTH PASADENA
State	:	CA
Zip	:	91030-4874
Country	:	US
Telephone Number	:	626-441-5000
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2007
Last Update Date	:	07/08/2007

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