Healthcare Provider Details

I. General information

NPI: 1316234149
Provider Name (Legal Business Name): RODERICK LEE MCBRIDE DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RICK L MCBRIDE DDS

II. Dates (important events)

Enumeration Date: 06/30/2011
Last Update Date: 06/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

890 SUNSET DR B-1A
HOLLISTER CA
95023-5651
US

IV. Provider business mailing address

890 SUNSET DR B-1A
HOLLISTER CA
95023-5651
US

V. Phone/Fax

Practice location:
  • Phone: 831-636-9808
  • Fax: 831-636-9843
Mailing address:
  • Phone: 831-636-9808
  • Fax: 831-636-9843

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number31497
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: