MEDICARE: WILLOW GLEN DENTAL SPECIALISTS

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy	License Number
1	122300000X	Dentist	DDS54347
2	1223E0200X	Endodontics
3	1223P0300X	Periodontics
4	1223X0400X	Orthodontics and Dentofacial Orthopedics Dentistry
5	1223S0112X	Oral and Maxillofacial Surgery (Dentist)

General Provider Information

NPI Number	:	1609385020
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLOW GLEN DENTAL SPECIALISTS

Provider Business Mailing Address
First Line	:	1706 WILLOW ST STE A
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5216
Country	:	US
Telephone Number	:	408-478-9081
Fax Number	:	408-904-7201

Provider Business Practice Location Address
First Line	:	1706 WILLOW ST STE A
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95125-5216
Country	:	US
Telephone Number	:	408-504-4935
Fax Number	:

Authorized Official
Title or Position	:	MEDICAL BILLING SPECIALIST
Name	:	ROSIE ADAME
Credential	:
Telephone Number	:	408-266-6144

Provider Enumeration Date	:	09/28/2017
Last Update Date	:	05/10/2018

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