Provider Demographics
NPI:1104176817
Name:DOSSANTOS, MAURICIO (DDS)
Entity type:Individual
Prefix:DR
First Name:MAURICIO
Middle Name:
Last Name:DOSSANTOS
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12033 4TH ST STE 7
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-2755
Mailing Address - Country:US
Mailing Address - Phone:909-790-1951
Mailing Address - Fax:909-790-1561
Practice Address - Street 1:12033 4TH ST STE 7
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-2755
Practice Address - Country:US
Practice Address - Phone:909-790-1951
Practice Address - Fax:909-790-1561
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-11
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA617111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice