Provider Demographics
NPI:1154923548
Name:DEL ROSARIO, GRACE LACSON
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:LACSON
Last Name:DEL ROSARIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32364 DYER ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1720
Mailing Address - Country:US
Mailing Address - Phone:510-324-2000
Mailing Address - Fax:510-288-1394
Practice Address - Street 1:35111 NEWARK BLVD STE A
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:CA
Practice Address - Zip Code:94560-1258
Practice Address - Country:US
Practice Address - Phone:510-494-0404
Practice Address - Fax:510-494-1621
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADDS406441223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice