2015 Dental Provider Directory CCHP Senior Program (HMO) Optional Supplemental Dental Plan H0571_2015_31 Accepted HL_DCU_6609_07.28.2014_CCHP
CCHP Senior Program (HMO) Optional Supplemental Dental Plan Dental Provider Directory This directory provides a list of DeltaCare USA providers available to the CCHP Senior Program (HMO) Optional Supplemental Dental Plan. This directory is for San Francisco and Northern San Mateo Counties. This directory is current as of August 2014. Some plan providers may have been added or removed from the list after this directory was printed. We do not guarantee that each provider is still accepting new members. To get the most up-to-date information about DeltaCare USA s providers in your area, you can call DeltaCare USA s Customer Service at 1-866-247-2486 (TTY/TDD: 1-800-735-2929), Monday through Friday between 5:00 a.m. and 6:00 p.m. (excluding holidays) Pacific time, or access the website at www.deltadentalins.com or call CCHP Member Services at 1-888-775-7888, 8:00 a.m. to 8:00 p.m. 7 days a week, (TTY/TDD: 1-877-681-8898.) CCHP Senior Program (HMO) is an HMO plan with a Medicare contract. Enrollment in CCHP Senior Program (HMO) depends on contract renewal. CCHP Senior Program (HMO) es un plan de atención coordinada que tiene un contrato con Medicare. La inscripción en CCHP Senior Program (HMO) depende de la renovación del contrato. 東 華 耆 英 (HMO) 計 劃 是 一 個 HMO 與 聯 邦 保 健 簽 有 合 約, 而 東 華 耆 英 (HMO) 計 劃 能 否 接 收 會 員 取 決 於 這 合 約 是 否 獲 得 續 約 This information is available for free in other languages. Please contact our customer service number at 1-888- 775-7888 (TTY 1-877-681-8898) from 8:00 a.m. to 8:00 p.m., seven days a week. Esta información está disponible gratuitamente en otros idiomas. Por favor póngase en contacto con nuestro número de servicio al cliente al 1-888-775-7888 (TTY 1-877-681-8898) de 8:00 a.m. a 8:00 p.m., siete días a la semana. 此 文 件 有 其 它 的 語 言 版 本 免 費 提 供 了 解 詳 情 請 致 電 1-888-775-7888 與 會 員 服 務 中 心 聯 絡 ( 聽 力 殘 障 人 仕 請 電 TTY1-877-681-8898), 每 週 7 天, 上 午 8 時 至 晚 上 8 時 This document may be available in other formats, such as Braille, large print, or other alternate formats. You may call CCHP Senior Program (HMO) Member Services at 1-888-775-7888 for more information. TTY users should call 1-877-681-8898. H0571_2015_31 Accepted
Section 1 Introduction This directory provides a list of DeltaCare USA providers available to the CCHP Senior Program (HMO) Optional Supplemental Dental Plan. To get detailed information about your dental coverage, please see your CCHP Senior Program (HMO) Evidence of Coverage, as well as your DeltaCare USA Dental HMO Program Benefit Booklet ( Evidence of Coverage ), which will be mailed along with your DeltaCare USA ID card. Contract Dentists When you enroll in the CCHP Senior Program (HMO) Optional Supplemental Dental Plan, you must select a Contract Dentist from the DeltaCare USA network. A Contract Dentist is a dentist who provides services in general dentistry and has agreed to provide benefits to enrollees under this program. Please refer to the list of Participating DeltaCare USA Providers for Contract Dentists that are available in the service area. Or, you may access the website at www.deltadentalins.com to view DeltaCare USA Contract Dentists near your home or work. You must indicate the provider name and number of your selected Contract Dentist on your dental enrollment form. The network providers listed in this directory have agreed to provide you with your dental coverage. You may choose one of the network providers listed in the directory to be your Contract Dentist; however, some services may require a referral. If you have been going to one Contract Dentist, you are not required to continue going to that same Contract Dentist. You may change your Contract Dentist by contacting Delta Dental Customer Service prior to the 21st of the month, and the change will take effect the first day of the following month. Your selected Contract Dentist will design a treatment plan to meet your individual needs. Prior to beginning treatment, it is best to discuss your treatment plan and financial responsibilities with your Contract Dentist. Dental services that are not performed by your Contract Dentist, or are not covered under emergency care, must be pre-authorized by Delta Dental to be covered by DeltaCare USA. In some cases, you may get covered services from non-network providers. You must use DeltaCare USA providers except in emergency or urgent care situations. If you obtain routine care from out-of-network providers neither Medicare nor CCHP/DeltaCare USA will be responsible for the costs. You are covered for out-of-network dental emergencies, up to $100 of dental expenses per emergency. When you receive a bill for emergency care or other services that have been pre-authorized by Delta Dental, but not performed by your Contract Dentist, you should submit the bill to Delta Dental for processing and determination of liability. The bill should be submitted within 90 days of the end of treatment to Delta Dental. Referrals to DeltaCare USA Contract Specialists During the course of treatment, your selected Contract Dentist may recommend the services of a Contract Specialist. Your selected Contract Dentist is responsible for coordinating your dental care and if necessary, referring you to a DeltaCare USA Contract Specialist, and will submit all required documentation for any necessary referral.
Emergency Dental Services If emergency services are needed, you should contact your Contract Dentist whenever possible. If you are a new enrollee needing emergency services, but do not have an assigned Contract Dentist yet, contact Delta Dental s Customer Service Department at 1-866-247-2486, Monday through Friday from 5:00 a.m. to 6:00 p.m. Pacific time (TTY/TDD: 1-800-735-2929) for help in locating a Contract Dentist. Benefits for emergency services by an out-of-network dentist are limited to necessary care to stabilize your condition and/or provide palliative relief when you: 1) Have made a reasonable attempt to contact the Contract Dentist and the Contract Dentist is unavailable or you cannot be seen within 24 hours of making contact; or 2) Have made a reasonable attempt to contact Delta Dental prior to receiving emergency services, or it is reasonable for you to access emergency services without prior contact with Delta Dental; or 3) Reasonably believe that your condition makes it dentally/medically inappropriate to travel to the Contract Dentist to receive emergency services. Benefits for emergency services not provided by the Contract Dentist are limited to a maximum of $100.00 per emergency, per enrollee, less the applicable copayment. If the maximum is exceeded, or the above conditions are not met, you are responsible for any charges for services by a provider other than your Contract Dentist. You must use plan providers except in emergency situations. If you obtain routine care from out-of-network providers neither Medicare nor CCHP/DeltaCare USA will be responsible for the costs. During non-business hours or if you are 35 miles or more from your assigned Contract Dentist, you do not need a referral and may seek treatment from any dentist other than your assigned Contract Dentist. If you do not require emergency dental services and a delay in receiving treatment would not be detrimental to your health, please contact your Contract Dentist or DeltaCare USA Customer Service Department at 1-866-247-2486, Monday through Friday between 5:00 a.m. to 6:00 p.m. (excluding holidays) (TTY/TDD: 1-800-735-2929) to make reasonable arrangements for your care. What is the service area for the CCHP Senior Program (HMO) Optional Supplemental Dental Plan? The counties in our service area are listed below. San Francisco County San Mateo County, the following zip codes only: 94005, 94010, 94011, 94014, 94015, 94016, 94017, 94019, 94030, 94037, 94038, 94044, 94066, 94080, 94083, 94128, 94401, 94402, 94403, 94404, 94407, 94497
How to find a DeltaCare USA provider in your area? The DeltaCare USA providers in this directory are listed alphabetically by City, Provider Number, and Provider Name. To find a DeltaCare USA provider in your area, first look for your city, then look for your zip code. Listing in this directory does not guarantee that the dentist is still in the network or accepting new patients. Once you become effective with the dental plan, simply call the Contract Dentist you selected and schedule an appointment. Most dental facilities are open during regular business hours. If you have questions about when the dental facility of your selected Contract Dentist is open, simply call the dental facility directly. The address and telephone number of your selected Contract Dentist is listed in this Dental Provider Directory. You may also call DeltaCare USA s Customer Service at 1-866-247-2486 (TTY/TDD: 1-800-735-2929), Monday through Friday between 5:00 a.m. and 6:00 p.m. (excluding holidays) for information regarding the Contract Dentist you selected or call CCHP Member Services at 1-888-775-7888, 8:00 a.m. to 8:00 p.m., 7 days a week (TTY: 1-877-681-8898).
Participating DeltaCare USA Dental Offices A Registered Mark of Delta Dental Plans Open Offices August 2014 BELMONT #154501 BELMONT PLAZA DENTAL CARE 390 EL CAMINO REAL STE D, 94002 2006 (650) 631 2893 F/T 2 (RU) #045495 MARIA LOURDES Y YEO DDS 2130 RALSTON AVE STE I D, 94002 (650) 591 4704 F/T 3 BURLINGAME #011568 MASHA MEKHTEYS, DDS 1860 EL CAMINO REAL STE 315, 94010 3114 (650) 692 0555 (RU) DALY CITY #026261 BELLA LIM, DDS 7455 EL CAMINO REAL STE C, 94014 2977 (650) 994 4561 #015677 CAMPUS HEIGHTS DENTAL 901 CAMPUS DR STE 304, 94015 4930 (650) 756 1900 #045497 MARIA LOURDES Y YEO DDS 2055 GELLERT BLVD #4, 94015 (650) 754 1300 F/T 3 #043355 MARIVIC AGONCILLO DDS INC 343 GELLERT BLVD STE G, 94015 2620 (650) 731 0625 #136201 MOUHANNAD AL MAJDALANI, DDS 320 WASHINGTON ST APT 105, 94015 1972 (650) 994 1111 (CH, AR, TA, SP) #142601 RODOLFO VILLASIN, DMD 341 WESTLAKE CTR STE 237, 94015 1446 (650) 756 6211 (TA) #047745 SERRAMONTE SMILE CENTER 347 GELLERT BLVD STE K, 94015 (650) 757 5380 FOSTER CITY #013159 JING JING QIAN, DDS 1289 E HILLSDALE BLVD STE 3, 94404 1219 (650) 572 8518 (CH) MENLO PARK #012522 JOSEPH K SARKOSH, DDS 888 OAK GROVE AVE STE 6, 94025 4428 (650) 327 8081 (SP) 1 MILLBRAE #005507 CECILIA JU, DDS 140 EL CAMINO, 94030 (650) 259 9896 (CH) #037727 DENTAL EASE 1070 BROADWAY, 94030 1944 (650) 697 3273 #033681 PEDRO CATURAY, DDS 1301 BROADWAY STE 7, 94030 1336 (650) 589 3667 (TA, SP) REDWOOD CITY #031550 BIRCH DENTAL GROUP 155 BIRCH ST STE 5, 94062 1340 (650) 366 0552 #012387 EUGENE ESPIRITU 705 VETERANS BLVD STE SUITE1, 94063 1735 (650) 298 8818 (CA, CH, SP, TA) #031062 UNITED DENTAL 647 VETERANS BLVD, 94063 1408 (650) 367 4300 #036284 WESTERN DENTAL SERVICES 975 VETERANS BLVD, 94063 1714 (650) 365 8900 F/T 4 P/T 29 07/29/2014 DR_DCU_CCHP_6609_AUG2014_07.28.2014 PLCCHP
SAN BRUNO #336601 EUGENE ESPIRITU 1230 EL CAMINO REAL STE K, 94066 1300 (650) 875 6808 #029379 SAN BRUNO DENTAL CARE 211 EL CAMINO REAL, 94066 4838 (650) 589 4784 F/T 2 (SP, TA, GE) SAN FRANCISCO #051951 ALEXANDER KOGAN DDS INC 255 KING ST STE A, 94107 (415) 644 0644 #082801 BERNARDO GONZALEZ, DDS 2720 24TH ST, 94110 4212 (415) 282 4566 (SP) #014142 CENTER OF COSMETIC DENTISTRY 1550 LOMBARD ST, 94123 3154 (415) 921 5555 #NONE00 DeltaCare USA Null Facility 100 FIRST STREET 9TH FLOOR, 94105 #058401 GENTLE DENTAL 2494 MISSION ST, 94110 2415 (415) 821 1200 F/T 2 P/T 4 (SP, RU) #144101 GENTLE DENTAL SAN FRANCISCO 2364 GEARY BLVD, 94115 3305 (415) 921 6722 P/T 2 (CA, SP, CH) #132801 GRAND MISSION DENTAL GROUP 4749 MISSION ST, 94112 2729 (415) 469 7444 (TA, SP) #151701 HIPOLITO BARONIA, DDS 2480 MISSION ST STE 214, 94110 2480 (415) 821 7847 (TA, SP) #121801 J T DENTAL 2415 NORIEGA ST, 94122 4241 (415) 682 2415 (CA, 12, SP) #022751 KAYVAN KAFAYI, DDS 450 SUTTER ST RM 1433, 94108 4010 (415) 398 2360 #265501 MAT KIISK, DDS 3100 19TH AVE, 94132 2006 (415) 584 2537 F/T 2 #033063 MICHAEL COLE, DDS 2595 MISSION ST STE 308, 94110 2574 (415) 647 9191 (SP) #134701 MIKHAIL BERDICHEVSKY, DDS 4444 GEARY BLVD STE 303, 94118 3045 (415) 386 5590 (RU) #048127 MISSION DENTAL 2482 MISSION ST, 94110 (415) 285 9900 F/T 2 (SP) #184601 NORIEGA DENTAL 3749 NORIEGA ST, 94122 3903 (415) 661 8851 (CA, CH) #008428 OCEAN DENTAL OFFICE 760 LA PLAYA ST, 94121 3262 (415) 221 5592 (12, RU, CH, TA, SP, CA) #136501 RICHMOND DENTAL CARE 4312 GEARY BLVD, 94118 3004 (415) 752 5605 F/T 2 (CH, SP, RU) #023138 ROBERTO CALABIO DMD INC 3184 22ND ST, 94110 3232 (415) 642 2050 #319201 RONALD YOUNG, DDS 1637 LOMBARD ST, 94123 3006 (415) 928 3777 (SP, 12, CA) #150101 SAN BRUNO AVE DENTAL CLINIC 2817 SAN BRUNO AVE, 94134 1510 (415) 656 2868 (12, SP, CH) #213501 SOUTH VAN NESS DENTAL GROUP 240 SHOTWELL ST STE 230, 94110 1323 (415) 431 9797 (SP) #212701 VAN NESS DENTAL GROUP 2243 VAN NESS AVE STE 101, 94109 2504 (415) 441 2098 F/T 4 (VI, 12, SP, CH, CA) 2
#039640 WESTERN DENTAL SERVICES 1282 MARKET ST, 94102 4801 (415) 552 1200 F/T 3 6 (SP) #039642 WESTERN DENTAL SERVICES 2813 MISSION ST, 94110 3907 (415) 285 7500 3 1 (SP) SAN MATEO #037686 A + DENTAL CENTER 400 N SAN MATEO DR 2, 94401 2418 (650) 343 0895 (CA, SP, TA) #037665 DECCAN DENTAL 1528 S EL CAMINO REAL #408, 94402 (650) 477 6920 F/T 2 (HI, CA, CH) #277501 GEORGE WOLFF, DDS 255 N SAN MATEO DR, 94401 2655 (650) 347 7100 #2C0001 PENINSULA DENTAL 401 A N SAN MATEO DR, 94401 (650) 344 7626 P/T 2 #046444 TAOS DENTAL CARE 1927 S EL CAMINO REAL, 94403 (650) 952 2689 F/T 2 #042548 WESTERN DENTAL SERVICES 4100 S EL CAMINO REAL, 94403 5131 (650) 235 1460 F/T 2 P/T 9 (SP) SOUTH SAN FRANCISCO #040747 CECILIA R H AVENIDO DMD INC 2400 WESTBOROUGH BLVD STE200, 94080 5402 (650) 989 8502 (TA, SP) #115101 GRAND MISSION DENTAL GROUP 125 NORTHWOOD DR STE A, 94080 5755 (650) 225 0202 (SP, TA) #024022 JEANETTE ESTIPONA, DDS 2400 WESTBOROUGH BLVD # 103, 94080 5402 (650) 296 6952 (TA) #2C2301 NORTHWOOD DENTAL CARE 125 NORTHWOOD DR STE A, 94080 5755 (650) 827 9746 #041328 PURE SMILE DENTAL GROUP 1133 EL CAMINO REAL STE# 5, 94080 (650) 244 9928 (TA, CH) #014628 TRINITY DENTAL CARE 1124 MISSION RD, 94080 1301 (650) 872 3030 (TA) 3
Visit us at our website: deltadentalins.com F/T Full Time Dentist P/T Part Time Dentist AF Afrikaans AR Arabic AM Armenian CA Cantonese CH Chinese CL Creole CS Czech EI East Indian FR French GE German GR Greek HE Hebrew HI Hindi HR Croatian Foreign languages spoken in the dental office are listed by code in ( ). Below is a key to the foreign language codes. HU Hungarian IN Indonesian IT Italian JA Japanese KO Korean PE Persian PL Polish RO Romanian RU Russian SP Spanish/ Español TA Tagalog TH Thai TR Turkish VI Vietnamese LANGUAGE ASSISTANCE: Language capabilities are self reported by the individual dental facilities and not independently verified by Delta Dental. If an enrollee requires language assistance to enable communication in a dental setting, Delta Dental will arrange for professional services through a certified interpretation vendor at no cost to the enrollee. Additional Dental Offices will be added as required. You may call our Customer Service department at 1 866 247 2486 Monday through Friday between 5 a.m. and 6 p.m. (excluding holidays) (TDD/TTY: 1 800 735 2929) for updates to the provider list. If any office is closed to further enrollment, Delta Dental reserves the right to assign you another dental office as close to your home as possible. In California, DeltaCare USA is underwritten by Delta Dental of California and administered by Delta Dental Insurance Company. NOTE: Contact the provider before making your choice if you have scheduling problems or small children. This document may be available in other formats, such as Braille, large print, or other alternate formats. You may call CCHP Senior Program (HMO) Member Services at 1 888 775 7888 for more information. TTY users should call 1 877 681 8898. The wheelchair symbol indicates functional accessibility for individuals with limited mobility. Information regarding dental office accessibility for patients with mobility impairments is available by calling Delta Dental s Customer Service department at 1 866 247 2486 Monday through Friday between 5 a.m. and 6 p.m. (excluding holidays) (TDD/TTY: 1 800 735 2929) 4