Provider Demographics
NPI:1487969028
Name:SYCAMORE FAMILY DENTISTRY
Entity type:Organization
Organization Name:SYCAMORE FAMILY DENTISTRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ELMER
Authorized Official - Middle Name:SANTOS
Authorized Official - Last Name:DE LEON
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:510-799-2900
Mailing Address - Street 1:1581 SYCAMORE AVE
Mailing Address - Street 2:SUITE 3
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1700
Mailing Address - Country:US
Mailing Address - Phone:510-799-2900
Mailing Address - Fax:510-799-2902
Practice Address - Street 1:1581 SYCAMORE AVE
Practice Address - Street 2:SUITE 3
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-1700
Practice Address - Country:US
Practice Address - Phone:510-799-2900
Practice Address - Fax:510-799-2902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA556191223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty