MEDICARE: DR. SACHIKO VIRGINIA FUKUMAN 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	28554	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	652268	OTHER	CA	UNITED CONCORDIA PROVIDER

General Provider Information

NPI Number	:	1861409534
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SACHIKO VIRGINIA FUKUMAN DDS

Provider Business Mailing Address
First Line	:	653 CAMINO DE LOS MARES STE 113
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-2856
Country	:	US
Telephone Number	:	949-248-7772
Fax Number	:	949-248-0516

Provider Business Practice Location Address
First Line	:	653 CAMINO DE LOS MARES STE 113
Second Line	:
City	:	SAN CLEMENTE
State	:	CA
Zip	:	92673-2856
Country	:	US
Telephone Number	:	949-248-7772
Fax Number	:	949-248-0516

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

Provider Enumeration Date	:	08/02/2006
Last Update Date	:	07/08/2007

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