Provider Demographics
NPI:1588704852
Name:ATIENZA, REGIS M JR (DDM)
Entity type:Individual
Prefix:DR
First Name:REGIS
Middle Name:M
Last Name:ATIENZA
Suffix:JR
Gender:M
Credentials:DDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2519 LAKEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204
Mailing Address - Country:US
Mailing Address - Phone:209-466-4262
Mailing Address - Fax:
Practice Address - Street 1:2237 GELLERT BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080
Practice Address - Country:US
Practice Address - Phone:650-878-1033
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40786122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist