Healthcare Provider Details

I. General information

NPI: 1912184474
Provider Name (Legal Business Name): BRANCH DENTAL CLINIC BRIDGEPORT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/28/2008
Last Update Date: 12/18/2017
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: 760-725-3213
  • Fax: 760-725-8223
Mailing address:
  • Phone: 760-725-3213
  • Fax: 760-725-8223

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: MR. WILLIAM MICHAEL CONDON
Title or Position: NAVY MEDICINE UBO PROGRAM MANAGER
Credential:
Phone: 240-401-3643