Healthcare Provider Details

I. General information

NPI: 1811259856
Provider Name (Legal Business Name): SAN DIEGO DENTAL SLEEP THERAPY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 06/14/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8530 LA MESA BLVD SUITE 204
LA MESA CA
91942-0966
US

IV. Provider business mailing address

8530 LA MESA BLVD SUITE 204
LA MESA CA
91942-0966
US

V. Phone/Fax

Practice location:
  • Phone: 619-460-0714
  • Fax: 619-460-0707
Mailing address:
  • Phone: 619-460-0714
  • Fax: 619-460-0707

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number31914
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number31914
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number31914
License Number StateCA

VIII. Authorized Official

Name: DR. RICHARD B EVANS
Title or Position: PRESIDENT
Credential: D.D.S.
Phone: 619-460-0714