Healthcare Provider Details

I. General information

NPI: 1205803566
Provider Name (Legal Business Name): CARL ERIK OPSAHL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43000 MIDWAY AVE
SAN DIEGO CA
92140-5692
US

IV. Provider business mailing address

2888 W PORTER RD
SAN DIEGO CA
92106-6083
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-4009
  • Fax:
Mailing address:
  • Phone: 619-524-4014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number32159
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: