Provider Demographics
NPI:1063841096
Name:SERGIO VICUNA DENTAL CORPORATION
Entity Type:Organization
Organization Name:SERGIO VICUNA DENTAL CORPORATION
Other - Org Name:DAVIS SMILES DENTISTRY DENTAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SERGIO
Authorized Official - Middle Name:
Authorized Official - Last Name:VICUNA
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:310-451-5060
Mailing Address - Street 1:17000 RED HILL AVENUE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:ORANGE
Mailing Address - Zip Code:92614
Mailing Address - Country:UM
Mailing Address - Phone:714-845-8890
Mailing Address - Fax:949-474-1495
Practice Address - Street 1:4515 FERMI PLACE SUITE 106
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95618
Practice Address - Country:US
Practice Address - Phone:310-451-5060
Practice Address - Fax:310-451-5062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-12
Last Update Date:2013-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty