Provider Demographics
NPI:1669480992
Name:MARY ANN V SANVICTORES DDS INC
Entity Type:Organization
Organization Name:MARY ANN V SANVICTORES DDS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DENTIST CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:VERGARA
Authorized Official - Last Name:SANVICTORES
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:619-628-8123
Mailing Address - Street 1:600 PALM AVENUE
Mailing Address - Street 2:SUITE 116
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-1245
Mailing Address - Country:US
Mailing Address - Phone:619-628-8123
Mailing Address - Fax:619-628-8081
Practice Address - Street 1:600 PALM AVENUE
Practice Address - Street 2:SUITE 116
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-1245
Practice Address - Country:US
Practice Address - Phone:619-628-8123
Practice Address - Fax:619-628-8081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA44360122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty