Provider Demographics
NPI:1669521050
Name:SURILLO, SANTIAGO ALFONSO (DDS MS)
Entity type:Individual
Prefix:
First Name:SANTIAGO
Middle Name:ALFONSO
Last Name:SURILLO
Suffix:
Gender:M
Credentials:DDS MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SPRING STREET
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941
Mailing Address - Country:US
Mailing Address - Phone:619-461-6166
Mailing Address - Fax:619-461-2508
Practice Address - Street 1:4700 SPRING STREET
Practice Address - Street 2:SUITE 104
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941
Practice Address - Country:US
Practice Address - Phone:619-461-6166
Practice Address - Fax:619-461-2508
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA410451223P0221X, 1223X0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223P0221XDental ProvidersDentistPediatric Dentistry
No1223X0400XDental ProvidersDentistOrthodontics and Dentofacial Orthopedics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA515327Medicare ID - Type Unspecified