Healthcare Provider Details

I. General information

NPI: 1316119290
Provider Name (Legal Business Name): MCGANN FACIAL DESIGN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 FROST ST #310
SAN DIEGO CA
92123
US

IV. Provider business mailing address

7910 FROST ST #310
SAN DIEGO CA
92123
US

V. Phone/Fax

Practice location:
  • Phone: 858-874-8181
  • Fax: 858-429-7010
Mailing address:
  • Phone: 858-874-8181
  • Fax: 858-429-7010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QS0112X
TaxonomyOral and Maxillofacial Surgery Clinic/Center
License Number52892
License Number StateCA

VIII. Authorized Official

Name: NATALIA WOLCOFF
Title or Position: OFFICE MANAGER
Credential:
Phone: 858-874-8181