Provider Demographics
NPI:1619151149
Name:PERFECT SMILES FAMILY DENTISTRY
Entity Type:Organization
Organization Name:PERFECT SMILES FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROCHELLE
Authorized Official - Middle Name:KENNEDY
Authorized Official - Last Name:BARACEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:925-833-8702
Mailing Address - Street 1:9260 ALCOSTA BLVD
Mailing Address - Street 2:SUITE B-10
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-4134
Mailing Address - Country:US
Mailing Address - Phone:925-833-8702
Mailing Address - Fax:925-833-3750
Practice Address - Street 1:9260 ALCOSTA BLVD
Practice Address - Street 2:SUITE B-10
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-4134
Practice Address - Country:US
Practice Address - Phone:925-833-8702
Practice Address - Fax:925-833-3750
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-19
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA555611223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty