Healthcare Provider Details

I. General information

NPI: 1497741672
Provider Name (Legal Business Name): ERIC DRIVER DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 01/28/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4060 4TH AVE SUITE #303
SAN DIEGO CA
92103-2116
US

IV. Provider business mailing address

4076 PENINSULA DR
CARLSBAD CA
92010-5564
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-0905
  • Fax:
Mailing address:
  • Phone: 816-210-2196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223G0001X
TaxonomyGeneral Practice Dentistry
License Number2004017842
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code1223P0300X
TaxonomyPeriodontics
License Number59069
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code122300000X
TaxonomyDentist
License Number59069
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: