Provider Demographics
NPI:1336279702
Name:SACHIKO FUKUMAN, DDS INC
Entity Type:Organization
Organization Name:SACHIKO FUKUMAN, DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SACHIKO
Authorized Official - Middle Name:VIRGINIA
Authorized Official - Last Name:FUKUMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:949-248-7772
Mailing Address - Street 1:653 CAMINO DE LOS MARES
Mailing Address - Street 2:SU. 113
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-2808
Mailing Address - Country:US
Mailing Address - Phone:949-248-7772
Mailing Address - Fax:949-248-0516
Practice Address - Street 1:653 CAMINO DE LOS MARES
Practice Address - Street 2:SU. 113
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2808
Practice Address - Country:US
Practice Address - Phone:949-248-7772
Practice Address - Fax:949-248-0516
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA285541223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA652268OtherUNITED CONCORDIA PROVIDER