Provider Demographics
NPI:1043740970
Name:EUSEBIO, TEDDY BELGICA (DDS)
Entity Type:Individual
Prefix:
First Name:TEDDY
Middle Name:BELGICA
Last Name:EUSEBIO
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1242 PARK ST STE A
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-5500
Mailing Address - Country:US
Mailing Address - Phone:510-865-6890
Mailing Address - Fax:
Practice Address - Street 1:1242 PARK ST STE A
Practice Address - Street 2:
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-5500
Practice Address - Country:US
Practice Address - Phone:510-865-6890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-13
Last Update Date:2018-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1032421223G0001X
MI29010223061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA36645932OtherDENTPIN
MI36645932OtherDENTPIN