MEDICARE: DR. NOLASCO T STA ANA D.M.D.

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	122300000X	Dentist	035341	CA

General Provider Information

NPI Number	:	1942553722
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NOLASCO T STA ANA D.M.D.

Provider Business Mailing Address
First Line	:	2560 WEST LINCOLN AVENUE
Second Line	:
City	:	ANAHEIM
State	:	CA
Zip	:	92801-6432
Country	:	US
Telephone Number	:	714-110-9647
Fax Number	:	714-220-0375

Provider Business Practice Location Address
First Line	:	1252 WEST 6TH STREET
Second Line	:	SUITE 103
City	:	CORONA
State	:	CA
Zip	:	92882-8207
Country	:	US
Telephone Number	:	951-371-7998
Fax Number	:

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

Provider Enumeration Date	:	10/18/2012
Last Update Date	:	10/18/2012

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