Healthcare Provider Details

I. General information

NPI: 1639275621
Provider Name (Legal Business Name): RANCHO SAN DIEGO DENTAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2648 JAMACHA RD SUITE 166
EL CAJON CA
92019-4346
US

IV. Provider business mailing address

2648 JAMACHA RD SUITE 166
EL CAJON CA
92019-4346
US

V. Phone/Fax

Practice location:
  • Phone: 619-670-5571
  • Fax: 619-670-5592
Mailing address:
  • Phone: 619-670-5571
  • Fax: 619-670-5592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number26243
License Number StateCA

VIII. Authorized Official

Name: GERALD P. WEINER
Title or Position: OWNER
Credential: DDS
Phone: 619-670-5571