Provider Demographics
NPI:1235594474
Name:SANTOS, LAUREL (DDS)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:
Last Name:SANTOS
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:LAUREL
Other - Middle Name:
Other - Last Name:MORA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:1402 PENNSYLVANIA AVE.
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533
Mailing Address - Country:US
Mailing Address - Phone:707-386-1264
Mailing Address - Fax:
Practice Address - Street 1:1402 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94533-3507
Practice Address - Country:US
Practice Address - Phone:707-386-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA619961223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice