Healthcare Provider Details

I. General information

NPI: 1710548375
Provider Name (Legal Business Name): SAN DIEGO DENTAL ANESTHESIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1287 CARLSBAD VILLAGE DRIVE
CARLSBAD CA
92008
US

IV. Provider business mailing address

8677 VILLA LA JOLLA DR # 1255
LA JOLLA CA
92037-2354
US

V. Phone/Fax

Practice location:
  • Phone: 619-339-0760
  • Fax:
Mailing address:
  • Phone: 619-339-0760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: TYLER JOHNSON
Title or Position: PRESIDENT
Credential: DDS
Phone: 619-339-0760