Provider Demographics
NPI:1881884930
Name:FILLMORE DENTAL SPA
Entity type:Organization
Organization Name:FILLMORE DENTAL SPA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CECILA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANTOS-BERKOWITZ
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:415-614-9850
Mailing Address - Street 1:3220 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94123-3403
Mailing Address - Country:US
Mailing Address - Phone:415-614-9850
Mailing Address - Fax:415-614-9881
Practice Address - Street 1:3220 FILLMORE ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123-3403
Practice Address - Country:US
Practice Address - Phone:415-614-9850
Practice Address - Fax:415-614-9881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2007-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA435901223P0300X
CA436561223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No1223P0300XDental ProvidersDentistPeriodonticsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA53490OtherPERIODONTIST
CA43656OtherGENERAL DENTIST