Provider Demographics
NPI:1245504356
Name:QUINTANILLA, ODETTE MORENA (DDS)
Entity type:Individual
Prefix:DR
First Name:ODETTE
Middle Name:MORENA
Last Name:QUINTANILLA
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:ODETTE
Other - Middle Name:MORENA
Other - Last Name:CASTILLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:208 VINTAGE WAY
Mailing Address - Street 2:STE K23
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94945-5014
Mailing Address - Country:US
Mailing Address - Phone:415-898-5100
Mailing Address - Fax:
Practice Address - Street 1:208 VINTAGE WAY
Practice Address - Street 2:STE K23
Practice Address - City:NOVATO
Practice Address - State:CA
Practice Address - Zip Code:94945-5014
Practice Address - Country:US
Practice Address - Phone:415-898-5100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA471601223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice