Provider Demographics
NPI:1245737931
Name:FAMILY DENTISTRY SAN BRUNO, INCORPORATED
Entity Type:Organization
Organization Name:FAMILY DENTISTRY SAN BRUNO, INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST AND OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIA CORAZON
Authorized Official - Middle Name:ROQUE
Authorized Official - Last Name:DAVID-ARROBIO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:650-866-3084
Mailing Address - Street 1:105 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-5426
Mailing Address - Country:US
Mailing Address - Phone:650-866-3084
Mailing Address - Fax:650-866-3081
Practice Address - Street 1:105 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066-5426
Practice Address - Country:US
Practice Address - Phone:650-866-3084
Practice Address - Fax:650-866-3081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-09
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44859261QD0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental