Provider Demographics
NPI:1689872194
Name:URRESTI SOBERON, JOSE E (DDS)
Entity Type:Individual
Prefix:DR
First Name:JOSE
Middle Name:E
Last Name:URRESTI SOBERON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 OLD TRAIL DR
Mailing Address - Street 2:
Mailing Address - City:CROZET
Mailing Address - State:VA
Mailing Address - Zip Code:22932-3342
Mailing Address - Country:US
Mailing Address - Phone:434-282-5469
Mailing Address - Fax:
Practice Address - Street 1:1470 PANTOPS MOUNTAIN PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-4600
Practice Address - Country:US
Practice Address - Phone:434-817-1817
Practice Address - Fax:434-817-1819
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CT102581223G0001X
VA04014138191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program