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1663 Dominican Way Suite 112 Santa Cruz CA 95065-1527 | |
| (831) 475-0221 | |
| (831) 475-3573 |
| Full Name | |
|---|---|
| Speciality | Dentist - Oral And Maxillofacial Surgery |
| Location | 1663 Dominican Way, Santa Cruz, California |
| Authorized Official Name and Position | Tyese K Evans (PRACTICE ADMINISTRATOR) |
| Authorized Official Contact | 8314750221 |
| Accepts Medicare Insurance | This clinic does not participate in Medicare Program. |
| Mailing Address | Practice Location Address |
|---|---|
1663 Dominican Way Suite 112 Santa Cruz CA 95065-1527 Ph: (831) 475-0221 | 1663 Dominican Way Suite 112 Santa Cruz CA 95065-1527 Ph: (831) 475-0221 |
| NPI Number | 1881869337 |
|---|---|
| Provider Enumeration Date | 04/25/2008 |
| Last Update Date | 04/25/2011 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1881869337 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 1223S0112X | Dentist - Oral And Maxillofacial Surgery | 23580 (California) | Primary |
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