Healthcare Provider Details

I. General information

NPI: 1952608291
Provider Name (Legal Business Name): TED WASSEL D.D.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1030 LA BONITA DR SUITE 322
SAN MARCOS CA
92078-5291
US

IV. Provider business mailing address

1030 LA BONITA DR SUITE 322
SAN MARCOS CA
92078-5291
US

V. Phone/Fax

Practice location:
  • Phone: 760-744-1919
  • Fax: 760-744-4625
Mailing address:
  • Phone: 760-744-1919
  • Fax: 760-744-4625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number40040
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: