Healthcare Provider Details

I. General information

NPI: 1659555886
Provider Name (Legal Business Name): NAVAL DENTAL CLINIC CAMP PENDLETON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 11/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14TH STREET BUILDING 13128
CAMP PENDLETON CA
92055-5221
US

IV. Provider business mailing address

PO BOX 555221
CAMP PENDLETON CA
92055-5221
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-5208
  • Fax: 760-725-5779
Mailing address:
  • Phone: 760-725-5208
  • Fax: 760-725-5779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM M CONDON
Title or Position: BUMED UBO
Credential:
Phone: 240-401-3643