Provider Demographics
NPI:1407253073
Name:WILFREDO L SANCIANCO DMD INC
Entity Type:Organization
Organization Name:WILFREDO L SANCIANCO DMD INC
Other - Org Name:WILFREDO SANCIANCO DMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTIST/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILFREDO
Authorized Official - Middle Name:L
Authorized Official - Last Name:SANCIANCO
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:401-737-7716
Mailing Address - Street 1:3411 W SHORE RD
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:RI
Mailing Address - Zip Code:02886-7561
Mailing Address - Country:US
Mailing Address - Phone:401-737-7716
Mailing Address - Fax:401-737-7713
Practice Address - Street 1:3411 W SHORE RD
Practice Address - Street 2:
Practice Address - City:WARWICK
Practice Address - State:RI
Practice Address - Zip Code:02886-7561
Practice Address - Country:US
Practice Address - Phone:401-737-7716
Practice Address - Fax:401-737-7713
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI02633122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1104221738Medicaid