Provider Demographics
NPI:1366581548
Name:SOBREPENA, VICTOR (DDS)
Entity type:Individual
Prefix:
First Name:VICTOR
Middle Name:
Last Name:SOBREPENA
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 1:12 HUCKLEBERRY CT
Mailing Address - Street 2:
Mailing Address - City:BRISBANE
Mailing Address - State:CA
Mailing Address - Zip Code:94005-1264
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:565 PILGRIM DR
Practice Address - Street 2:SUITE A
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1245
Practice Address - Country:US
Practice Address - Phone:650-525-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA413111223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223G0001XDental ProvidersDentistGeneral Practice