Healthcare Provider Details

I. General information

NPI: 1497115547
Provider Name (Legal Business Name): WOLF AND BEAR DENTAL CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2016
Last Update Date: 03/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3023 BUNKER HILL ST STE 105
SAN DIEGO CA
92109-5706
US

IV. Provider business mailing address

3023 BUNKER HILL ST STE 105
SAN DIEGO CA
92109-5706
US

V. Phone/Fax

Practice location:
  • Phone: 425-306-2579
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223D0004X
TaxonomyDental Anesthesiology
License Number
License Number State

VIII. Authorized Official

Name: STEVEN DELISLE
Title or Position: OWNER
Credential:
Phone: 425-306-2579