Active NPI
Genesis Profeta Antonio, D.D.S.
- General Practice Dentistry
- Fairfield, CA
National Provider Identifier
1326113291
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 48076
- Practice address
- 650 Empire St
Suite B
Fairfield, CA 94533-5527 - Phone
- (707) 428-7171
- Fax
- (707) 428-7179
- NPI assigned
- Nov 22, 2006
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 48076 | CA | Primary |
Addresses
Primary practice location
650 Empire St
Suite B
Fairfield, CA 94533-5527
Mailing address
650 Empire St
Suite B
Fairfield, CA 94533-5527
Phone (707) 428-7171
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 48076 | CA | MD | General Practice Dentistry |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1164153600000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1183852800000",
"number": "1326113291",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "650 EMPIRE ST",
"address_2": "SUITE B",
"city": "FAIRFIELD",
"state": "CA",
"postal_code": "945335527",
"telephone_number": "707-428-7171",
"fax_number": "707-428-7179"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "650 EMPIRE ST",
"address_2": "SUITE B",
"city": "FAIRFIELD",
"state": "CA",
"postal_code": "945335527",
"telephone_number": "707-428-7171",
"fax_number": "707-428-7179"
}
],
"practiceLocations": [],
"basic": {
"last_name": "ANTONIO",
"first_name": "GENESIS",
"middle_name": "PROFETA",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2006-11-22",
"last_updated": "2007-07-08",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "CA",
"license": "48076",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Fairfield, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jul 8, 2007; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.