Healthcare Provider Details

I. General information

NPI: 1487769121
Provider Name (Legal Business Name): CORENE J. POELMAN, D.D.S., M.S., APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/21/2006
Last Update Date: 06/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16466 BERNARDO CENTER DR SUITE 176
SAN DIEGO CA
92128-2508
US

IV. Provider business mailing address

16466 BERNARDO CENTER DR SUITE 176
SAN DIEGO CA
92128-2508
US

V. Phone/Fax

Practice location:
  • Phone: 858-676-6709
  • Fax: 858-676-6739
Mailing address:
  • Phone: 858-676-6709
  • Fax: 858-676-6739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223E0200X
TaxonomyEndodontics
License Number44355
License Number StateCA

VIII. Authorized Official

Name: DR. CORENE JANNA POELMAN
Title or Position: OWNER/ENDODONTIST
Credential: D.D.S., M.S.
Phone: 858-676-6709