Provider Demographics
NPI:1548707441
Name:SHEPARD & DOS SANTOS DENTAL CORPORATION
Entity type:Organization
Organization Name:SHEPARD & DOS SANTOS DENTAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:WOLF
Authorized Official - Last Name:DOS SANTOS
Authorized Official - Suffix:
Authorized Official - Credentials:DA
Authorized Official - Phone:424-277-1138
Mailing Address - Street 1:310 E GRAND AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:EL SEGUNDO
Mailing Address - State:CA
Mailing Address - Zip Code:90245-3871
Mailing Address - Country:US
Mailing Address - Phone:760-453-5702
Mailing Address - Fax:
Practice Address - Street 1:310 E GRAND AVE STE 102
Practice Address - Street 2:
Practice Address - City:EL SEGUNDO
Practice Address - State:CA
Practice Address - Zip Code:90245-3871
Practice Address - Country:US
Practice Address - Phone:760-453-5702
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41704122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Single Specialty