Provider Demographics
NPI:1538298625
Name:SERRANO, PERCY PONCHO (PERCY SERRANO)
Entity Type:Individual
Prefix:
First Name:PERCY
Middle Name:PONCHO
Last Name:SERRANO
Suffix:
Gender:M
Credentials:PERCY SERRANO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6541 CROWN BLVD
Mailing Address - Street 2:SUITE G
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95120-2907
Mailing Address - Country:US
Mailing Address - Phone:408-268-4161
Mailing Address - Fax:408-268-5745
Practice Address - Street 1:6541 CROWN BLVD
Practice Address - Street 2:SUITE G
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95120-2907
Practice Address - Country:US
Practice Address - Phone:408-268-4161
Practice Address - Fax:408-268-5745
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA284861223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice