MEDICARE: SAN JOSE DENTAL SURGERY CENTER, 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	261QD0000X	Dental Clinic/Center	D52747	CA
2	261QA1903X	Ambulatory Surgical Clinic/Center	D52747	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	D52747	OTHER	CA	DENTI-CAL LICENSE NUMBER

General Provider Information

NPI Number	:	1902086606
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SAN JOSE DENTAL SURGERY CENTER, INC.

Provider Business Mailing Address
First Line	:	2048 STORY RD
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95122-1668
Country	:	US
Telephone Number	:	408-240-9000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2048 STORY RD
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95122-1668
Country	:	US
Telephone Number	:	408-240-9000
Fax Number	:

Authorized Official
Title or Position	:	VICE PRESIDENT
Name	:	KHAM NGUYEN
Credential	:	DDS
Telephone Number	:	408-240-9000

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	04/05/2025

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