Healthcare Provider Details

I. General information

NPI: 1396139127
Provider Name (Legal Business Name): BURGETT DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2015
Last Update Date: 03/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4541 COLLEGE AVE
SAN DIEGO CA
92115-4010
US

IV. Provider business mailing address

4541 COLLEGE AVE
SAN DIEGO CA
92115-4010
US

V. Phone/Fax

Practice location:
  • Phone: 619-582-6000
  • Fax: 619-582-6002
Mailing address:
  • Phone: 619-582-6000
  • Fax: 619-582-6002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code126800000X
TaxonomyDental Assistant
License Number
License Number State

VIII. Authorized Official

Name: RAY BAHAE
Title or Position: PARTNER
Credential:
Phone: 858-361-3322