Healthcare Provider Details

I. General information

NPI: 1013978477
Provider Name (Legal Business Name): DAVID P DEROSIER DDS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2006
Last Update Date: 05/05/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3019 EMERSON STREET
SAN DIEGO CA
92106-2603
US

IV. Provider business mailing address

3019 EMERSON STREET
SAN DIEGO CA
92106-2603
US

V. Phone/Fax

Practice location:
  • Phone: 619-222-7400
  • Fax: 619-222-7018
Mailing address:
  • Phone: 619-222-7400
  • Fax: 619-222-7018

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number35869
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number35869
License Number StateCA

VIII. Authorized Official

Name: DAVID PAUL DEROSIER
Title or Position: DR OWNER
Credential: DDS
Phone: 619-222-7400