MEDICARE: DR. MARY ALICIA DELSOL D.D.S.

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	1223S0112X	Oral and Maxillofacial Surgery (Dentist)	D32544	CA

General Provider Information

NPI Number	:	1629030994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY ALICIA DELSOL D.D.S.

Provider Business Mailing Address
First Line	:	32241 CROWN VALLEY PKWY
Second Line	:	STE. 220
City	:	DANA POINT
State	:	CA
Zip	:	92629-3346
Country	:	US
Telephone Number	:	949-240-2280
Fax Number	:	949-240-2619

Provider Business Practice Location Address
First Line	:	32241 CROWN VALLEY PKWY
Second Line	:	STE. 220
City	:	DANA POINT
State	:	CA
Zip	:	92629-3346
Country	:	US
Telephone Number	:	949-240-2280
Fax Number	:	949-240-2619

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

Provider Enumeration Date	:	04/03/2006
Last Update Date	:	07/08/2007

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