Healthcare Provider Details

I. General information

NPI: 1457462228
Provider Name (Legal Business Name): MICHAEL KEVIN GAVIN D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 12/27/2019
Certification Date: 12/27/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5680 LAKE MURRAY BLVD STE B
LA MESA CA
91942-1905
US

IV. Provider business mailing address

5680 LAKE MURRAY BLVD STE B
LA MESA CA
91942-1905
US

V. Phone/Fax

Practice location:
  • Phone: 858-208-6042
  • Fax:
Mailing address:
  • Phone: 604-285-8208
  • Fax: 619-462-4312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number37420
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: