Provider Demographics
NPI:1932650249
Name:MARIA TERESA R DE GUZMAN DDS CORP
Entity Type:Organization
Organization Name:MARIA TERESA R DE GUZMAN DDS CORP
Other - Org Name:MYTOOTHSPA DENTISTRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:E
Authorized Official - Last Name:DEGUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-919-5721
Mailing Address - Street 1:5060 SUNRISE BLVD
Mailing Address - Street 2:STE A4
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628-4944
Mailing Address - Country:US
Mailing Address - Phone:916-910-0708
Mailing Address - Fax:916-910-0751
Practice Address - Street 1:5060 SUNRISE BLVD
Practice Address - Street 2:SUITE A1
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628-4944
Practice Address - Country:US
Practice Address - Phone:916-863-0456
Practice Address - Fax:916-910-0751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41390261QS0112X, 305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
No261QS0112XAmbulatory Health Care FacilitiesClinic/CenterOral and Maxillofacial Surgery