Provider Demographics
NPI:1891853149
Name:R. CICCARELLI, DDS., R. JOSEPH, DDS., M. EL FARRA, DDS., D. SAINI, DDS
Entity type:Organization
Organization Name:R. CICCARELLI, DDS., R. JOSEPH, DDS., M. EL FARRA, DDS., D. SAINI, DDS
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CORPORATE TREASURER
Authorized Official - Prefix:DR
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOREHEAD
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:209-823-9341
Mailing Address - Street 1:1507 W. YOSEMITE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95337
Mailing Address - Country:US
Mailing Address - Phone:209-823-9341
Mailing Address - Fax:209-823-5091
Practice Address - Street 1:1507 W. YOSEMITE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95337
Practice Address - Country:US
Practice Address - Phone:209-823-9341
Practice Address - Fax:209-823-5091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-05
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53028122300000X
CA50181122300000X
CA54048122300000X
CA35699122300000X
CA42922122300000X
CA51062122300000X
CA26998122300000X
CA34614122300000X
CA38406122300000X
CA59209122300000X
CA28362122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty