MEDICARE: DR. MAURICIO RONDEROS DDS, MS, MPH

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	1223P0300X	Periodontics	47787	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	47787	OTHER	CA	DENTAL LINSENCE

General Provider Information

NPI Number	:	1457402034
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAURICIO RONDEROS DDS, MS, MPH

Provider Business Mailing Address
First Line	:	358 MARINE PKWY STE 300
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94065-5211
Country	:	US
Telephone Number	:	650-595-5083
Fax Number	:	650-594-9236

Provider Business Practice Location Address
First Line	:	358 MARINE PKWY STE 300
Second Line	:
City	:	REDWOOD CITY
State	:	CA
Zip	:	94065-5211
Country	:	US
Telephone Number	:	650-595-5083
Fax Number	:	650-594-9236

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

Provider Enumeration Date	:	01/12/2007
Last Update Date	:	07/08/2007

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