Healthcare Provider Details

I. General information

NPI: 1487879110
Provider Name (Legal Business Name): HANNA LAEL ROBIN DE BOURG DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3105 HARBOR BLVD
COSTA MESA CA
92626
US

IV. Provider business mailing address

3105 HARBOR BLVD
COSTA MESA CA
92626
US

V. Phone/Fax

Practice location:
  • Phone: 310-922-2170
  • Fax:
Mailing address:
  • Phone: 310-922-2170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number48096
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: