Provider Demographics
NPI:1750023743
Name:COULTER, ALYSSA GIANELLA
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:GIANELLA
Last Name:COULTER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 PINE ST
Mailing Address - Street 2:
Mailing Address - City:MILLBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94030-2019
Mailing Address - Country:US
Mailing Address - Phone:650-274-3328
Mailing Address - Fax:
Practice Address - Street 1:1528 S EL CAMINO REAL STE 408
Practice Address - Street 2:
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3067
Practice Address - Country:US
Practice Address - Phone:650-212-3500
Practice Address - Fax:650-212-3505
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-10
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1094061223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice