Provider Demographics
NPI:1962952762
Name:SANTA CRUZ DENTAL GROUP
Entity type:Organization
Organization Name:SANTA CRUZ DENTAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MAX
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:831-426-3535
Mailing Address - Street 1:1017 MISSION ST
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-3524
Mailing Address - Country:US
Mailing Address - Phone:831-426-3535
Mailing Address - Fax:831-454-0330
Practice Address - Street 1:1017 MISSION ST
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-3524
Practice Address - Country:US
Practice Address - Phone:831-426-3535
Practice Address - Fax:831-454-0330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32389122300000X
CA50398122300000X
CA50395122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13261317131OtherDOCTOR'S NPI NUMBERS
CA1063505477OtherDOCTOR'S NPI NUMBERS
CA1639272248OtherDOCTOR'S NPI NUMBERS