Provider Demographics
NPI:1083890206
Name:VILLAFUERTE, ERNESTO ANTONIO (DDS)
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:ANTONIO
Last Name:VILLAFUERTE
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:ERNESTO
Other - Middle Name:A
Other - Last Name:VILLAFUERTE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DDS
Mailing Address - Street 1:1001 SNEATH LANE
Mailing Address - Street 2:#307
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066
Mailing Address - Country:US
Mailing Address - Phone:650-246-0454
Mailing Address - Fax:650-246-0439
Practice Address - Street 1:1001 SNEATH LANE
Practice Address - Street 2:#307
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066
Practice Address - Country:US
Practice Address - Phone:650-246-0454
Practice Address - Fax:650-246-0439
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-17
Last Update Date:2008-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA33530122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist