Provider Demographics
NPI:1730205626
Name:BERONILLA, EMEGIO GARCIA SR (DMD)
Entity type:Individual
Prefix:DR
First Name:EMEGIO
Middle Name:GARCIA
Last Name:BERONILLA
Suffix:SR
Gender:M
Credentials:DMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2480 MISSION ST STE 214
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-2480
Mailing Address - Country:US
Mailing Address - Phone:415-655-3614
Mailing Address - Fax:415-947-7986
Practice Address - Street 1:2480 MISSION ST STE 214
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2480
Practice Address - Country:US
Practice Address - Phone:415-655-3614
Practice Address - Fax:415-947-7986
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2017-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320261223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA248651OtherPIN NUMBER