Healthcare Provider Details

I. General information

NPI: 1154159408
Provider Name (Legal Business Name): DEYO DENTAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2024
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

960 W SAN MARCOS BLVD STE 100
SAN MARCOS CA
92078-1122
US

IV. Provider business mailing address

1293 HOLMGROVE DR
SAN MARCOS CA
92078-2800
US

V. Phone/Fax

Practice location:
  • Phone: 310-913-9013
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223X0400X
TaxonomyOrthodontics and Dentofacial Orthopedics Dentistry
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. LAURA DEYO
Title or Position: ORTHODONTIST
Credential: DDS, MS
Phone: 310-913-9013