Provider Demographics
NPI:1811011430
Name:JUSTINIANO, FATIMA (DDS)
Entity type:Individual
Prefix:MRS
First Name:FATIMA
Middle Name:
Last Name:JUSTINIANO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34900 NEWARK BLVD
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:CA
Mailing Address - Zip Code:94560-1216
Mailing Address - Country:US
Mailing Address - Phone:510-795-6470
Mailing Address - Fax:510-795-6471
Practice Address - Street 1:34900 NEWARK BLVD
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-1216
Practice Address - Country:US
Practice Address - Phone:510-795-6470
Practice Address - Fax:510-795-6471
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA468361223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG98663-01OtherHEALTHY FAMILY PROVIDER
CAG89988-01OtherDENTICAL PROVIDER NUMBER