Healthcare Provider Details

I. General information

NPI: 1730817404
Provider Name (Legal Business Name): THEODORE SLAGLE DMD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2022
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5638 MISSION CENTER RD STE 107
SAN DIEGO CA
92108-4348
US

IV. Provider business mailing address

4770 HARBINSON AVE
LA MESA CA
91942-8755
US

V. Phone/Fax

Practice location:
  • Phone: 215-380-8689
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDDS110296
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: