Provider Demographics
NPI:1578642872
Name:COUNTY OF SANTA CLARA
Entity Type:Organization
Organization Name:COUNTY OF SANTA CLARA
Other - Org Name:TULLY MOBILE DENTAL UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:DR
Authorized Official - First Name:ALFONSO
Authorized Official - Middle Name:F
Authorized Official - Last Name:BANUELOS
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:408-885-4001
Mailing Address - Street 1:PO BOX 5280
Mailing Address - Street 2:PATIENT BUSINESS SERVICES
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95150-5280
Mailing Address - Country:US
Mailing Address - Phone:408-885-5000
Mailing Address - Fax:
Practice Address - Street 1:500 TULLY RD
Practice Address - Street 2:TULLY DENTAL MOBILE UNIT
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1917
Practice Address - Country:US
Practice Address - Phone:408-885-5000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA261QD0000X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental
Not Answered261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC80070FMedicaid