Healthcare Provider Details

I. General information

NPI: 1982903324
Provider Name (Legal Business Name): POISET DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2011
Last Update Date: 08/17/2021
Certification Date: 08/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7930 FROST ST SUITE 101
SAN DIEGO CA
92123-2737
US

IV. Provider business mailing address

7930 FROST ST SUITE 101
SAN DIEGO CA
92123-2737
US

V. Phone/Fax

Practice location:
  • Phone: 858-492-9977
  • Fax: 858-492-9910
Mailing address:
  • Phone: 858-492-9977
  • Fax: 858-492-9910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223P0221X
TaxonomyPediatric Dentistry
License NumberB32650
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License NumberB32650
License Number StateCA

VIII. Authorized Official

Name: DR. MITCHELL B POISET
Title or Position: OWNER/CEO
Credential:
Phone: 858-492-9977