Healthcare Provider Details

I. General information

NPI: 1710023213
Provider Name (Legal Business Name): ANTHONY P VARBONCOEUR DDC INC & CORTLAND S CALDEMEYER DDS APC GP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR BLD 1 STE 129
LA MESA CA
91942
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DR BLD 1 STE 129
LA MESA CA
91942
US

V. Phone/Fax

Practice location:
  • Phone: 619-463-4486
  • Fax: 619-463-6553
Mailing address:
  • Phone: 619-463-4486
  • Fax: 619-463-6553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223P0106X
TaxonomyOral and Maxillofacial Pathology Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number37512
License Number State
# 3
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number47693
License Number State

VIII. Authorized Official

Name: DR. CORTLAND S. CALDEMEYER
Title or Position: PARTNER
Credential: DDS
Phone: 619-463-4486