Provider Demographics
NPI:1497382733
Name:VILLANUEVA, DENISE EBALO (DDS)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:EBALO
Last Name:VILLANUEVA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1828 SADDLE PARK AVE
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-2768
Mailing Address - Country:US
Mailing Address - Phone:408-688-6375
Mailing Address - Fax:
Practice Address - Street 1:995 MONTAGUE EXPY STE 210
Practice Address - Street 2:
Practice Address - City:MILPITAS
Practice Address - State:CA
Practice Address - Zip Code:95035-6885
Practice Address - Country:US
Practice Address - Phone:408-946-5858
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA106937122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty