Provider Demographics
NPI:1467105031
Name:CUPERTINO DENTAL SPECIALTY GROUP
Entity Type:Organization
Organization Name:CUPERTINO DENTAL SPECIALTY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MELINA
Authorized Official - Middle Name:
Authorized Official - Last Name:LUCCHINI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:408-257-3031
Mailing Address - Street 1:10383 TORRE AVE STE I
Mailing Address - Street 2:
Mailing Address - City:CUPERTINO
Mailing Address - State:CA
Mailing Address - Zip Code:95014-3238
Mailing Address - Country:US
Mailing Address - Phone:408-257-3031
Mailing Address - Fax:408-508-7530
Practice Address - Street 1:10373 TORRE AVENUE
Practice Address - Street 2:SUITE G
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-9501
Practice Address - Country:US
Practice Address - Phone:408-508-7560
Practice Address - Fax:408-508-7530
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CUPERTINO DENTAL GROUP PARTNERSHIP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-02-02
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
No1223E0200XDental ProvidersDentistEndodonticsGroup - Multi-Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Multi-Specialty