MEDICARE: SUMILAT 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	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1790325140
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUMILAT DDS, INC.

Provider Business Mailing Address
First Line	:	3053 PRADO LN
Second Line	:
City	:	COLTON
State	:	CA
Zip	:	92324-9545
Country	:	US
Telephone Number	:	909-824-3126
Fax Number	:

Provider Business Practice Location Address
First Line	:	11481 HEACOCK ST STE 160
Second Line	:
City	:	MORENO VALLEY
State	:	CA
Zip	:	92557-7906
Country	:	US
Telephone Number	:	909-824-3126
Fax Number	:

Authorized Official
Title or Position	:	C.E.O.
Name	:	JAMES SUMILAT
Credential	:	DDS
Telephone Number	:	909-824-3126

Provider Enumeration Date	:	01/14/2020
Last Update Date	:	01/14/2020

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