Healthcare Provider Details

I. General information

NPI: 1497403232
Provider Name (Legal Business Name): JEFFREY BROCKETT DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2022
Last Update Date: 03/14/2022
Certification Date: 03/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1349 CAMINO DEL MAR STE E
DEL MAR CA
92014-2553
US

IV. Provider business mailing address

3087 CRANBROOK CT
LA JOLLA CA
92037-2209
US

V. Phone/Fax

Practice location:
  • Phone: 323-632-3361
  • Fax:
Mailing address:
  • Phone: 323-632-3361
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1223X0008X
TaxonomyOral and Maxillofacial Radiology Dentistry
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: DR. JEFFREY E BROCKETT
Title or Position: PRESIDENT
Credential: DDS
Phone: 323-632-3361