Healthcare Provider Details

I. General information

NPI: 1699960864
Provider Name (Legal Business Name): JOSEPH L PACKER DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 09/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15825 LAGUNA CANYON RD
IRVINE CA
92618-2125
US

IV. Provider business mailing address

28081 EDELWEISS CT
LAGUNA NIGUEL CA
92677-7006
US

V. Phone/Fax

Practice location:
  • Phone: 949-789-8989
  • Fax: 949-453-0970
Mailing address:
  • Phone: 702-292-0759
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number58887
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number5560
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number6657777-9922
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: