Provider Demographics
NPI:1407918337
Name:SANTIAGO, FERNANDO BONIFACIO (DMD)
Entity Type:Individual
Prefix:DR
First Name:FERNANDO
Middle Name:BONIFACIO
Last Name:SANTIAGO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:665 S KNICKERBOCKER DR STE 9
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94087-1059
Mailing Address - Country:US
Mailing Address - Phone:408-739-5311
Mailing Address - Fax:408-739-2928
Practice Address - Street 1:665 S KNICKERBOCKER DR STE 9
Practice Address - Street 2:
Practice Address - City:SUNNYVALE
Practice Address - State:CA
Practice Address - Zip Code:94087-1059
Practice Address - Country:US
Practice Address - Phone:408-739-5311
Practice Address - Fax:408-739-2928
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23140122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist