Provider Demographics
NPI:1730245903
Name:SCIANAMBLO, MICHAEL JOHN (DDS)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JOHN
Last Name:SCIANAMBLO
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 1:1526 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1852
Mailing Address - Country:US
Mailing Address - Phone:415-457-3002
Mailing Address - Fax:415-457-0591
Practice Address - Street 1:1526 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-1852
Practice Address - Country:US
Practice Address - Phone:415-457-3002
Practice Address - Fax:415-457-0591
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA270651223E0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223E0200XDental ProvidersDentistEndodontics