1316171937 NPI number — LA JOLLA DENTAL SPECIALTY GROUP

Table of content: (NPI 1316171937)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316171937 NPI number — LA JOLLA DENTAL SPECIALTY GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LA JOLLA DENTAL SPECIALTY GROUP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316171937
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/11/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4510 EXECUTIVE DR
Provider Second Line Business Mailing Address:
SUITE 205
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92121-3021
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-546-1802
Provider Business Mailing Address Fax Number:
858-546-1242

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4510 EXECUTIVE DR
Provider Second Line Business Practice Location Address:
SUITE 205
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92121-3021
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-546-1802
Provider Business Practice Location Address Fax Number:
858-546-1242
Provider Enumeration Date:
05/11/2009

Additional Information

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
DUKE
Authorized Official Middle Name:
HUYNH
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
858-546-1802

Provider Taxonomy Codes

  • Taxonomy code: 1223E0200X , with the licence number:  47399 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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