Healthcare Provider Details

I. General information

NPI: 1598968810
Provider Name (Legal Business Name): JEFFREY W FRUIN DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2007
Last Update Date: 12/07/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3257 CAMINO DE LOS COCHES #306
CARLSBAD CA
92009
US

IV. Provider business mailing address

3257 CAMINO DE LOS COCHES #306
CARLSBAD CA
92009
US

V. Phone/Fax

Practice location:
  • Phone: 760-634-8100
  • Fax: 760-634-8130
Mailing address:
  • Phone: 760-634-8100
  • Fax: 760-634-8130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number034489
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: