Healthcare Provider Details

I. General information

NPI: 1053920934
Provider Name (Legal Business Name): TAIS TREVELIN LOWRY DMD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/28/2020
Last Update Date: 10/20/2025
Certification Date: 10/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15620 VIA MONTECRISTO
SAN DIEGO CA
92127-4142
US

IV. Provider business mailing address

15620 VIA MONTECRISTO
SAN DIEGO CA
92127-4142
US

V. Phone/Fax

Practice location:
  • Phone: 858-679-8918
  • Fax:
Mailing address:
  • Phone: 509-508-7395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License NumberDDS105858
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License NumberDDS105858
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: