Healthcare Provider Details

I. General information

NPI: 1609115336
Provider Name (Legal Business Name): JUSTIN JON PHILLIP CARL DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2013
Last Update Date: 06/10/2021
Certification Date: 06/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1225 ISLAND AVE UNIT 204
SAN DIEGO CA
92101-7567
US

IV. Provider business mailing address

9118 PIMPERNEL DR
SAN DIEGO CA
92129-3602
US

V. Phone/Fax

Practice location:
  • Phone: 209-406-4508
  • Fax:
Mailing address:
  • Phone: 209-406-4508
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number61913
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number61913
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: