Provider Demographics
NPI:1568000743
Name:FONSECA RICAURTE, MARIA ANGELICA (DDS)
Entity Type:Individual
Prefix:DR
First Name:MARIA
Middle Name:ANGELICA
Last Name:FONSECA RICAURTE
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:MARIA
Other - Middle Name:ANGELICA
Other - Last Name:VENKATA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:3700 CASA VERDE ST APT 2504
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-3338
Mailing Address - Country:US
Mailing Address - Phone:310-905-0335
Mailing Address - Fax:
Practice Address - Street 1:2999 REGENT ST STE 714
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2122
Practice Address - Country:US
Practice Address - Phone:510-848-3143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-12-18
Last Update Date:2019-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS1043831223P0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0700XDental ProvidersDentistProsthodontics