Provider Demographics
NPI:1295892388
Name:BANATAO, SOFRONIO TOLENTINO (DMD)
Entity type:Individual
Prefix:DR
First Name:SOFRONIO
Middle Name:TOLENTINO
Last Name:BANATAO
Suffix:
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35124 NEWARK BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-1220
Mailing Address - Country:US
Mailing Address - Phone:510-796-3441
Mailing Address - Fax:510-796-3475
Practice Address - Street 1:35124 NEWARK BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-1220
Practice Address - Country:US
Practice Address - Phone:510-796-3441
Practice Address - Fax:510-796-3475
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA387971223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice