Healthcare Provider Details

I. General information

NPI: 1518947704
Provider Name (Legal Business Name): MARK BREESE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 01/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1289 CARLSBAD VILLAGE DR
CARLSBAD CA
92008-1950
US

IV. Provider business mailing address

1289 CARLSBAD VILLAGE DR
CARLSBAD CA
92008-1950
US

V. Phone/Fax

Practice location:
  • Phone: 760-730-9333
  • Fax: 760-434-6016
Mailing address:
  • Phone: 760-730-9333
  • Fax: 760-434-6016

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number5652896
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number60626
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: