Provider Demographics
NPI:1326318197
Name:SCOPAZZI, THERESA NINA (DDS)
Entity Type:Individual
Prefix:DR
First Name:THERESA
Middle Name:NINA
Last Name:SCOPAZZI
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:MS
Other - First Name:THERESA
Other - Middle Name:NINA
Other - Last Name:SCOPAZZI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:36 N SAN MATEO DR STE C
Mailing Address - Street 2:
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94401-4523
Mailing Address - Country:US
Mailing Address - Phone:650-343-9434
Mailing Address - Fax:
Practice Address - Street 1:36 N SAN MATEO DR STE C
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94401-4523
Practice Address - Country:US
Practice Address - Phone:650-343-9434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-10
Last Update Date:2012-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA329011223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice