Healthcare Provider Details

I. General information

NPI: 1497946933
Provider Name (Legal Business Name): LAJOLLA COSMETIC & FAMILY DENTISTRY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2007
Last Update Date: 05/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

470 NAUTILUS ST # 212
LA JOLLA CA
92037
US

IV. Provider business mailing address

470 NAUTILUS ST # 212
LA JOLLA CA
92037
US

V. Phone/Fax

Practice location:
  • Phone: 858-459-5591
  • Fax: 858-459-4242
Mailing address:
  • Phone: 858-459-5591
  • Fax: 858-459-4242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number44055
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number44055
License Number StateCA

VIII. Authorized Official

Name: NICK PAVLOV
Title or Position: DENTIST
Credential: DDS
Phone: 858-459-5591