Healthcare Provider Details

I. General information

NPI: 1235492000
Provider Name (Legal Business Name): BRENDAN EGHTEDAR DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2012
Last Update Date: 06/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555020 BLDG, #1377
CAMP PENDLETON CA
92055-5020
US

IV. Provider business mailing address

PO BOX 17146
SAN DIEGO CA
92177-7146
US

V. Phone/Fax

Practice location:
  • Phone: 866-980-8989
  • Fax:
Mailing address:
  • Phone: 858-336-6451
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number54528
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: