Healthcare Provider Details

I. General information

NPI: 1538358643
Provider Name (Legal Business Name): NORTH PARK SMILES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2007
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3795 30TH ST
SAN DIEGO CA
92104-3631
US

IV. Provider business mailing address

3795 30TH ST
SAN DIEGO CA
92104-3631
US

V. Phone/Fax

Practice location:
  • Phone: 619-220-0548
  • Fax: 619-220-8604
Mailing address:
  • Phone: 619-220-0548
  • Fax: 619-220-8604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number44306
License Number StateCA

VIII. Authorized Official

Name: EDUARDO DIAZ
Title or Position: OWNER
Credential: DDS
Phone: 619-220-0549